Case Report: Zero-contrast multivessel PCI with left main bifurcation guided by dual IVUS strategies using a coronary...

Zero-contrast percutaneous coronary intervention (PCI) has emerged as an alternative strategy for patients with contraindications to iodinated contrast media. Nevertheless, the majority of reported cases depend on prior invasive coronary angiography for procedural planning, and experience using coronary computed tomography angiography (CTA) as the sole anatomical roadmap remains limited.

We present the case of a 38-year-old man admitted with non-ST-elevation myocardial infarction (NSTEMI) and complex multivessel coronary disease, in whom prior coronary computed tomography angiography (CTA) had triggered life-threatening anaphylactic shock. No subsequent invasive coronary angiography was performed; the pre-procedural roadmap was based solely on the CTA. Using intravascular ultrasound (IVUS) guidance, we successfully performed complete multivessel, zero-contrast PCI, including treatment of a left main (LM) bifurcation lesion. The right coronary artery lesion was treated with indirect IVUS guidance, marking landing zones on fluoroscopy before stent deployment. The long, ostial left anterior descending artery (LAD) lesion extending into the LM required direct IVUS guidance, with stent advancement and deployment under continuous live IVUS imaging. Post-procedural IVUS confirmed optimal expansion and apposition with no complications. The patient remained free of cardiovascular events through 24 months of follow-up.

Zero-contrast PCI guided by IVUS using a pre-procedural coronary CTA roadmap may be feasible in selected patients without prior invasive coronary angiography. Combining indirect and direct IVUS guidance may aid in managing complex lesions, which warrants further validation.