Staged Rotational Atherectomy-Assisted Multivessel PCI with a Cumulative 293 mm Drug-Eluting Stent Burden: Technical Strategy and Clinical Follow-Up

Extensive multivessel drug-eluting stent (DES) implantation is infrequently reported with longitudinal follow-up. We describe a 77-year-old man with Canadian Cardiovascular Society class III angina, insulin-treated diabetes, an LVEF of 30%, and heavily calcified multivessel disease (SYNTAX score 34). Coronary artery bypass grafting (CABG) was recommended after Heart Team review, but the patient declined surgery; diffuse distal disease also compromised potential graft targets. Staged PCI comprised rotational atherectomy and five DES (172 mm) for ostial/proximal LAD disease with contiguous distal-left-main plaque extension and a separate distal-Cx lesion, followed seven months later by four overlapping DES (121 mm) from the RCA crux/PL branch to the ostium. Total nominal stent length was 293 mm across separate coronary territories, not a continuous single-vessel construct. Antiplatelet therapy required temporary modifications for prostatic artery embolization, major gastrointestinal bleeding, and right hemicolectomy. Follow-up extended 913 days after the index PCI and 687 days after completion of both stages. No cardiovascular death, nonfatal myocardial infarction, repeat coronary revascularization, or definite or probable stent thrombosis was documented; LVEF was 55%. The report highlights staged technical decision-making and coordinated management of competing ischemic and bleeding risks. This single-patient observation cannot establish safety, durability, or equivalence to CABG.