An 84-year-old hypertensive and diabetic patient with end-stage chronic kidney disease presented with an acute coronary syndrome complicated by cardiac arrest. Coronary angiography revealed severe triple-vessel disease, including a heavily calcified left main coronary artery extending to the ostium of the left anterior descending artery, severe calcific stenosis of the ostium of the left circumflex artery, and significant disease of the right coronary artery. The patient was considered at extremely high operative risk, with a high SYNTAX score and advanced renal failure, making surgical revascularization unsuitable.

Despite these challenges, the patient was successfully treated with a complex percutaneous coronary intervention using an ultra-low contrast strategy. The procedure was fully intravascular ultrasound–guided, allowing precise lesion assessment and stent optimization while minimizing contrast exposure. Calcium modification was achieved using rotational atherectomy followed by intravascular lithotripsy to ensure adequate lesion preparation and optimal stent expansion. The intervention was completed with minimal contrast use, preserving residual renal function and avoiding further renal deterioration.

This case highlights that, even in elderly patients with severe chronic kidney disease, complex multivessel and left main percutaneous coronary interventions can be safely performed using ultra-low contrast techniques when appropriate imaging guidance and advanced calcium-modifying tools are available. Wider adoption of ultra-low contrast PCI should be encouraged in high-risk renal patients to improve outcomes and expand revascularization options.

Youness Toukami, MD, completed his Doctorate in General Medicine at Mohammed VI University of Health Sciences (UM6SS) and pursued specialty training in Cardiology at the Faculty of Medicine and Pharmacy of Casablanca (FMPC). In 2026, he is in his final (fourth) year of cardiology specialization. He is currently undertaking a Fellowship in Interventional Cardiology at Meditrina Hospital, a high-volume tertiary referral center recognized for its expertise in complex percutaneous coronary interventions, including left main and bifurcation PCI, chronic total occlusions, advanced calcium modification strategies, and structural heart disease interventions.