Coronary Artery Disease | Dr. Ge Junbo (Cardiology) | CMCS Shanghai

About Dr. Ge Junbo

Dr. Ge Junbo is Chief of Cardiology and Director of the Cardiovascular Interventional Centre at Zhongshan Hospital, Fudan University — one of China's foremost academic medical centres for complex coronary intervention and structural heart disease. He is widely recognised as a pioneer of interventional cardiology in China, with particular expertise in chronic total occlusion (CTO) revascularisation, severely calcified coronary lesions, and intravascular imaging-guided precision PCI. Dr. Ge led China's first clinical trials of biodegradable polymer drug-eluting stents and bioresorbable vascular scaffolds (BRS), and his centre is a national reference site for the application of intravascular ultrasound (IVUS), optical coherence tomography (OCT), and Shockwave intravascular lithotripsy (IVL) in complex coronary intervention. He has published extensively in leading international cardiovascular journals including JACC, EuroIntervention, and Circulation, and serves on the editorial boards of multiple international cardiology publications. His practice integrates imaging-guided precision, device innovation, and a whole-vessel management philosophy that has set the standard for complex PCI in China and across Asia.

Case Overview

Mr. David Harrington, a 64-year-old British retired engineer, presented with a three-year history of progressive exertional chest tightness and dyspnoea, acutely worsening over one week with nocturnal paroxysmal dyspnoea. Coronary angiography at Zhongshan Hospital revealed severe three-vessel disease: a 90% stenosis of the proximal-to-mid left anterior descending artery (LAD) with circumferential calcification exceeding 270° and a mid-segment chronic total occlusion (CTO) with TIMI 1 flow; a 70% bifurcation stenosis of the left circumflex artery (LCX, Medina 1,1,1); and a previously stented right coronary artery (RCA) with a patent in-stent segment. SYNTAX Score was 32 — formally indicating surgical revascularisation — but the patient declined coronary artery bypass grafting (CABG) and requested percutaneous coronary intervention (PCI). Dr. Ge Junbo designed a staged, imaging-guided revascularisation strategy: first, CTO recanalisation and calcification modification of the LAD using rotational atherectomy, cutting balloon, and Shockwave IVL under IVUS guidance, followed by drug-eluting stent (DES) implantation; second, DK Crush bifurcation stenting of the LCX. At six-month follow-up, the patient was angina-free, exercise tolerance had substantially improved, and coronary CT angiography confirmed LAD stent patency with no restenosis.

Patient Background

• Name / Nationality: Mr. David Harrington (pseudonym) — British
• Age / Sex: 64-year-old male
• Occupation: Retired civil engineer — previously active; progressive functional limitation over three years
• Chief Complaint: Recurrent chest tightness and dyspnoea for 3 years; acute worsening with nocturnal paroxysmal dyspnoea for 1 week
• Cardiovascular Risk Factors: Hypertension (15 years); Type 2 diabetes (10 years, HbA1c 7.8%); 30 pack-year smoking history (ceased 5 years prior); dyslipidaemia
• Prior Cardiac History: Inferior myocardial infarction 2 years prior — RCA PCI with one drug-eluting stent implanted
• ECG: ST-segment depression 1 mm in V1–V4; T-wave inversion
• Echocardiography: LVEF 52%; anterior wall hypokinesia; mild mitral regurgitation
• SYNTAX Score: 32 (high complexity — guideline recommendation: CABG; patient declined surgery and requested PCI)

Coronary Angiography and Diagnosis

Angiographic Findings

• LAD (Left Anterior Descending Artery): Diffuse proximal-to-mid disease; maximum stenosis 90%; severe circumferential calcification (calcium arc >270°); mid-segment chronic total occlusion (CTO); TIMI 1 flow
• LCX (Left Circumflex Artery): Proximal 70% stenosis; true bifurcation lesion — Medina classification 1,1,1
• RCA (Right Coronary Artery): Prior stent patent; distal vessel small calibre

Intravascular Imaging — IVUS Assessment (LAD)

• Calcification: 360° circumferential calcification confirmed; calcium arc exceeding the angiographic estimate
• Minimum lumen area (MLA): 2.1 mm² — severely flow-limiting
• Plaque morphology: Fibrous cap disruption; moderate thrombus burden
• Decision: High-pressure balloon dilatation alone carries unacceptable risk of coronary dissection or perforation — plaque modification mandatory prior to stenting

Clinical Diagnosis

• Severe three-vessel coronary artery disease — SYNTAX Score 32
• LAD proximal-to-mid severely calcified chronic total occlusion (CTO) — TIMI 1 flow
• LCX proximal true bifurcation stenosis — Medina 1,1,1
• RCA in-stent patency confirmed
• Reduced anterior wall function (LVEF 52%); mild mitral regurgitation

Clinical Decision Making

Three compounding challenges defined this case: a severely calcified CTO in the LAD — the dominant vessel supplying the anterior wall — in a patient with already impaired left ventricular function; a high SYNTAX Score formally recommending surgery in a patient who declined CABG; and the need to achieve complete revascularisation percutaneously without the safety net of surgical backup. Conventional balloon dilatation of a 360° calcified CTO carries a high risk of coronary perforation or acute vessel closure — outcomes that in a patient with LVEF 52% and a non-functional RCA territory could be haemodynamically catastrophic.

Dr. Ge Junbo's integrated strategy: This is not a case where we can simply cross the wire and inflate a balloon. The IVUS tells us everything the angiogram cannot: 360° calcium, minimum lumen area of 2.1 mm², fibrous cap disruption. If we attempt high-pressure dilatation without plaque modification, we are not treating the lesion — we are creating a dissection. The correct sequence is: open the CTO with the right wire strategy, then modify the calcium in three steps — rotational atherectomy to debulk, cutting balloon to score the fibrous ring, Shockwave IVL to fracture the deep calcium — and only then deploy the stent. IVUS guides every decision. We do not guess. We see.

Treatment Process

Phase 1 — CTO Recanalisation

Guiding catheter: EBU 3.5, 7F
Wire strategy: Fielder XT-A for initial CTO entry; escalated to Gaia Third for penetration of the calcified fibrous cap and advancement into the distal true lumen
Confirmation: Distal true lumen position confirmed by IVUS and contralateral injection

Initial balloon passage attempt with a 2.0 x 15 mm balloon failed — the balloon could not cross the lesion, confirming the severity of the calcification and the necessity of plaque modification before any further dilatation.

Dr. Ge's procedural note: CTO recanalisation in a calcified vessel is a wire selection problem before it is anything else. Fielder XT-A gives us the initial penetration force; Gaia Third gives us the torque response to navigate through the calcified cap and find the true lumen distally. Once the wire is across, the real work begins — because crossing the wire is only the beginning. The lesion still cannot be dilated safely.

Phase 2 — Calcification Modification (Combination Plaque Modification Strategy)

Step 1 — Rotational Atherectomy (Rotablator): A 1.5 mm burr was advanced to the lesion and rotational atherectomy performed at 160,000 rpm using a Dot-to-Dot technique — short, controlled passes to debulk the superficial calcium without thermal injury to the vessel wall. This created a channel sufficient for subsequent device passage.

Step 2 — Cutting Balloon: A 3.0 mm cutting balloon was advanced to the lesion and inflated — scoring the fibrous ring surrounding the calcified plaque and creating controlled longitudinal incisions to facilitate subsequent balloon expansion.

Step 3 — Shockwave Intravascular Lithotripsy (IVL): A 4.0 x 12 mm Shockwave IVL balloon was positioned at the target lesion and inflated to 6 atm. Ten sonic pressure pulses were delivered — selectively fracturing the deep calcified plaque through acoustic energy while preserving the surrounding soft tissue and vessel wall integrity.

Post-IVL angiography: calcium ring fracture confirmed; significant lumen gain achieved; no angiographically apparent dissection.

Dr. Ge's procedural note: The combination of rotational atherectomy, cutting balloon, and Shockwave IVL is not redundant — each tool addresses a different component of the calcified plaque. Rotablator debulks the superficial calcium and creates device access. The cutting balloon scores the fibrous ring. Shockwave IVL fractures the deep calcium that neither the burr nor the cutting balloon can reach — through acoustic pressure waves that pass through soft tissue without damaging it. This three-step combination is currently the most complete calcium modification strategy available. For a 360° calcified CTO, it is not optional. It is the only safe path to adequate stent expansion.

Phase 3 — Drug-Eluting Stent Implantation and Optimisation

Stent selection: A 3.5 x 38 mm biodegradable polymer drug-eluting stent (DES) was selected — covering the full lesion length with a single stent to avoid overlapping metal and preserve future treatment options. Note: Dr. Ge Junbo is one of China's principal investigators for biodegradable polymer DES and bioresorbable vascular scaffold (BRS) clinical trials; the Leave Nothing Behind philosophy — minimising permanent metallic implant burden — guides stent selection in eligible lesions.

Deployment: Stent deployed at 12 atm with precise positioning to cover the full lesion length without geographic miss at either edge.

Post-dilatation (POT — Proximal Optimisation Technique): A 4.0 mm non-compliant balloon was used for high-pressure post-dilatation — ensuring complete stent apposition to the vessel wall and eliminating any underexpansion at the proximal segment.

Final IVUS assessment:

• Minimum stent area (MSA): 7.8 mm² — well above the threshold for adequate expansion
• Stent expansion rate: 100%
• Edge assessment: No edge dissection; no geographic miss; complete lesion coverage confirmed

Dr. Ge's procedural note: The final IVUS is not a formality — it is the quality control step that determines whether this procedure will succeed long-term. MSA below 5.5 mm² in the LAD is the single strongest predictor of in-stent restenosis and stent thrombosis. We achieved 7.8 mm². That number is the result of the three-step calcium modification — without it, we would have been lucky to achieve 4.5 mm². IVUS does not just guide the procedure. It proves that the procedure was done correctly.

Phase 4 — LCX Bifurcation Stenting (Second Procedure)

In a staged second procedure, the LCX true bifurcation lesion (Medina 1,1,1) was treated using the DK Crush (Double Kissing Crush) technique — Dr. Ge's centre's standard approach for true bifurcation disease involving a significant side branch. The DK Crush technique ensures complete coverage of the bifurcation carina, optimal side branch ostial stenting, and final kissing balloon inflation to restore normal bifurcation geometry. Both the main vessel and the side branch were confirmed patent on final angiography and IVUS assessment.

Post-operative Management and Follow-up

Pharmacological Management

• Dual antiplatelet therapy (DAPT): Aspirin 100 mg daily + ticagrelor 90 mg twice daily — planned for 12 months, with bleeding risk reassessment at 6 months
• Lipid-lowering: Rosuvastatin 20 mg nightly — target LDL-C below 1.4 mmol/L (high-intensity statin therapy per post-ACS guidelines)
• Glycaemic control: SGLT-2 inhibitor added — providing both glycaemic control and cardiovascular/renal protection
• Blood pressure and heart failure prevention: ARNI (angiotensin receptor-neprilysin inhibitor) initiated — addressing both hypertension and the mild anterior wall dysfunction identified on echocardiography

6-Month Follow-up Assessment

• Symptoms: No angina; no dyspnoea at rest or on moderate exertion; exercise tolerance substantially improved
• Coronary CT angiography: LAD stent patent; no in-stent restenosis; LCX bifurcation stent patent with preserved side branch flow
• Echocardiography: LVEF improved to 58%; anterior wall motion normalised
• LDL-C: 1.1 mmol/L — target achieved

International Patient Follow-up

Dr. Ge's team established a bilingual (English and Chinese) follow-up record for Mr. Harrington, with direct communication between the Zhongshan Hospital cardiology team and his cardiologist in London — ensuring continuity of antiplatelet management, lipid monitoring, and long-term surveillance across healthcare systems.

Extended Case: Bioresorbable Vascular Scaffold for Young Patient with LAD Disease

Dr. Ge Junbo's Leave Nothing Behind philosophy is most powerfully applied in younger patients where the long-term consequences of permanent metallic implants are greatest. A 42-year-old Australian software engineer with a 75% proximal LAD stenosis and no significant calcification underwent IVUS-guided bioresorbable vascular scaffold (BRS) implantation — avoiding permanent metal implantation entirely. At 3-year follow-up, the scaffold had fully resorbed, the vessel had restored normal vasomotor function, and the patient remained angina-free on single antiplatelet therapy. This case was enrolled in the Zhongshan Hospital BRS registry, contributing to the evidence base for next-generation scaffold design in young patients with focal coronary disease.

Expert Commentary — Dr. Ge Junbo

1. No Imaging, No Intervention: The IVUS Imperative in Complex PCI

Coronary angiography shows us the silhouette of the lumen. IVUS shows us the vessel wall, the plaque, the calcium, the stent — in three dimensions, in real time. For a calcified CTO, the angiogram tells us there is a problem. IVUS tells us the nature of the problem: the calcium arc, the minimum lumen area, the fibrous cap morphology, the thrombus burden. Without that information, every decision in the procedure is a guess. With it, every decision is a measurement. In our centre, IVUS guidance is not optional for complex PCI — it is the standard of care. The data are unambiguous: IVUS-guided PCI reduces stent thrombosis, reduces restenosis, and reduces major adverse cardiac events compared with angiography-guided PCI alone. The question is not whether to use IVUS. The question is why anyone would not.

2. The Combination Approach to Calcification: Rotablator, Cutting Balloon, and Shockwave IVL

Severe coronary calcification is the most technically demanding problem in interventional cardiology. A single modality is rarely sufficient. Rotational atherectomy debulks the superficial calcium and creates device access — but it cannot fracture the deep calcium that prevents stent expansion. The cutting balloon scores the fibrous ring — but it cannot penetrate calcified plaque. Shockwave IVL delivers acoustic pressure waves that selectively fracture deep calcium through the balloon wall, without thermal injury, without vessel wall trauma, and without the risk of burr entrapment. The combination of all three — what we call the Combination Therapy approach — is currently the most complete calcium modification strategy available for 360° calcified lesions. Mastering this combination is the defining technical skill for the next generation of interventional cardiologists in China and globally.

3. Leave Nothing Behind: The Philosophy of Minimal Implant Burden

Every metallic stent implanted in a coronary artery is a permanent foreign body. It prevents future surgical bypass at that segment. It complicates future PCI. It carries a lifelong risk of very late stent thrombosis. For a 64-year-old patient, these risks are manageable. For a 42-year-old patient with 40 years of potential cardiac events ahead, they are not trivial. The Leave Nothing Behind philosophy — using biodegradable polymer DES, bioresorbable scaffolds, or drug-coated balloons wherever the lesion morphology permits — is not idealism. It is long-term risk management. We implant the minimum amount of metal necessary to achieve the best possible result. In lesions where full scaffold resorption is achievable, we aim to leave the patient with a vessel that is, in time, indistinguishable from a native coronary artery.

4. The Convergence of Coronary and Structural Heart Disease

Coronary artery disease and structural heart disease are not separate disciplines — they are expressions of the same underlying cardiovascular pathology. This patient's mild mitral regurgitation, identified on pre-procedural echocardiography, is a direct consequence of anterior wall ischaemia and left ventricular remodelling. As anterior wall function recovers following complete revascularisation, mitral regurgitation will likely improve — as it did, with LVEF recovering to 58% at six months. However, if mitral regurgitation were to progress despite successful revascularisation, transcatheter edge-to-edge repair (TEER — MitraClip or PASCAL) would be the next intervention. Our centre performs both complex PCI and structural heart disease intervention under the same roof, with the same imaging infrastructure and the same multidisciplinary team. For patients with combined coronary and structural disease, that integration is not a convenience — it is a clinical necessity.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported Mr. Harrington's care pathway from initial overseas inquiry through six-month post-procedural follow-up. Our coordination included:

• Pre-arrival review of prior cardiac records, RCA PCI operative report, echocardiography, and ECG findings; specialist referral to Dr. Ge Junbo's interventional cardiology team at Zhongshan Hospital, Fudan University
• Arrangement of comprehensive pre-procedural assessment: repeat ECG, echocardiography, renal function panel, coagulation screen, and HbA1c — with results reviewed by Dr. Ge's team prior to the patient's arrival in Shanghai
• Coordination of diagnostic coronary angiography: catheterisation laboratory scheduling, contrast allergy pre-medication protocol, and bilingual results communication including SYNTAX Score explanation and surgical versus percutaneous revascularisation options
• Bilingual interpretation during the treatment planning consultation — including detailed explanation of the CTO recanalisation strategy, three-step calcium modification rationale (rotational atherectomy, cutting balloon, Shockwave IVL), IVUS guidance protocol, stent selection philosophy, and realistic procedural risks and outcomes
• Facilitation of the patient's informed decision to decline CABG and proceed with staged PCI — ensuring the patient fully understood the higher procedural complexity and the importance of strict post-procedural medication adherence
• Staged procedure logistics: catheterisation laboratory scheduling for both the LAD CTO procedure and the LCX bifurcation procedure; accommodation support between procedures; daily clinical liaison with Dr. Ge's nursing team
• On-site medical interpretation throughout both hospitalisations, including IVUS findings explanation, post-procedural medication counselling (DAPT, statin, SGLT-2 inhibitor, ARNI), and discharge planning
• Pharmacological coordination: prescription translation, medication sourcing guidance for ticagrelor and rosuvastatin in the UK, and liaison with the patient's London cardiologist regarding DAPT duration and bleeding risk reassessment
• Six-month follow-up coordination: coronary CT angiography scheduling, results translation, and communication to the London cardiology team; LDL-C monitoring and statin dose optimisation liaison
• Long-term surveillance planning: annual cardiology review scheduling, echocardiographic follow-up for mitral regurgitation monitoring, and ongoing bilingual communication between Dr. Ge's team and the patient's UK cardiologist

For international patients facing complex, high-risk coronary artery disease — particularly those with severely calcified lesions, chronic total occlusions, multi-vessel disease, or prior treatment failures — the combination of IVUS-guided precision, Shockwave IVL capability, CTO recanalisation expertise, and the Leave Nothing Behind philosophy at Zhongshan Hospital represents a standard of interventional cardiology that is genuinely at the international frontier. CMCS exists to connect patients with that expertise: ensuring every revascularisation option is evaluated, every procedural decision is explained in their language, and every step from pre-arrival record review to long-term post-procedural surveillance is coordinated across borders with precision and care.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.