A Gentleman, aged 64 years/ Male, known case of Hypertension and Type-2 DM on treatment, came with complaints of chest pain and breathlessness on minimal exertion since 1 month, now progressed to symptoms at rest since 2 days; Considering rapidly progressive symptoms and associated risk factors, we advised CAG (Coronary Angiogram).

CAG revealed occlusions in two blood vessels supplying heart (RCA proximal 80-90% lesion( fig 1) & LAD proximal 90% calcified lesion (fig 4,5). He is advised PTCA with stent to RCA, and Rotablation followed by stent to LAD

PTCA with the stent to RCA done with 3.5mm x 24mm Promus Element stent. As the lesion is involving RCA origin, there was difficulty in cannulation and wiring RCA, which we overcame by using AL-1 catheter supported by the long sheath (fig 2), achieved a good result. As the LAD has calcified

bifurcation lesion, we did Rotablation for better stent expansion and to reduce diagonal compromise after LAD stenting. Successful rotablation has done with 1.5 burrs (fig 6) and pre-dila-tion done with 2.75mm x 18mm balloon. Even after adequate pre-dilation as there was difficulty in tracking stent, we used guidelines catheter (fig 7)to position stent across the lesion, achieved a good result in LAD too. Post-procedure hospital stays uneventful and discharged on day-2 and for regular follow-up.

Conclusion: Calcified lesions pose challenges to an intervention-al cardiologist as it may compromise long term results due to stent under expansion. Stent under expansion is an important and common cause of stent restenosis and stent thrombosis.

To circumvent these problems we use Rotablation (or) cutting balloon to modify plaque for better stent expansion.

Fig1: Rt Coronary Angiogram showing ostial RCA significant occlusion with filling defectRt Coronary Angiogram showing ostial RCA significant occlusion with filling defect

Fig2: Cannulation with AL 1 catheter as JR3.5 has not supported wiring. Post pre dilatation with 2.75 x 18 balloonCannulation with AL 1 catheter as JR3.5 has not supported wiring. Post pre dilatation with 2.75 x 18 balloon

Fig3: Post Stenting with 3.5×24 mm Promus element stent to RCA .Post Stenting with 3x28 mm Promus element stent

Fig4: Coronary Angiogram Showing proximal LAD discrete 90 % lesion.Coronary Angiogram Showing proximal LAD discrete 90 % lesion.

Fig5: Plain Cine Showing Proximal LAD calcification at the site of a lesion.Plain Cine Showing Proximal LAD calcification at the site of a lesion.

Fig 6: Rrotablation with 1.5 mm burr.Rrotablation with 1.5 mm burr.

Fig 7: Guide Liner Catheter to take support to Push StentGuide Liner Catheter to take support to Push Stent

Fig 8: Post Stenting with 3×28 mm Promus element stentPost Stenting with 3.5x24 mm Promus element stent to RCA .

 

 

Contributed by DR. A SHARATH REDDY { MD, DM, FSCAI, FACC }