Management of calcium in coronaries: Not always as expected

Percutaneous revascularization of calcified coronary lesions is being performed with increasing frequency. Particularly, in elderly patients at high bleeding risk (HBR), these procedures are rife with technical challenges, which need to be balanced against the need to adhere to the KISS (keep it simple and swift) principle, minimizing procedural complexity and duration. We report the case of a 75-year-old male with HBR, presenting with angina, in whom intravascular imaging-guided multivessel percutaneous revascularization was performed in vessels with coronary artery calcium (CAC). Rotational atherectomy was done for concentric calcification in the left anterior descending artery. CAC in a tortuous right coronary artery was tackled with a balloon-based strategy, with the help of a guide extension catheter (GEC), which itself led to long stent damage during manipulation, necessitating bailout. This case demonstrates the judicious use of available armamentarium in resource-limited settings for tackling different presentations of CAC and the appropriate selection of calcium-modifying strategy guided by intravascular imaging. We also emphasize the importance of exercising caution when using equipment such as GEC and the need for swift and appropriate bailout mechanisms of these complications.