Slides Coronary Left Main

Rotablation and Stent Insertion for Left Anterior Descending Artery Stenosis with Severe Calcification

- Operator : Duk-Woo Park

Rotablation and Stent Insertion for Left Anterior Descending Artery Stenosis with Severe Calcification
- Operator: Duk-Woo Park, MD
Case Presentation
A 65 year-old woman was admitted with chest discomfort for about one month. Her coronary risk factors were hypertension and diabetes mellitus. The physical examination was normal. The echocardiography showed normal left ventricular function (EF=65%) without regional wall motion abnormality.
Baseline Coronary Angiography
  1. The left coronary angiogram showed significant diffuse tight stenosis at proximal to middle left anterior descending artery (LAD) with heavy calcification ( Movie 1).
  2. Mild stenosis of proximal right coronary artery was checked (Figure 1).
Procedure
A 8 Fr sheath was inserted through right femoral artery, and the left coronary artery was engaged with an 8 Fr JL 4.0 catheter with side hole. The 0.014 inch BMW wire was inserted into the LAD. First, we checked the LAD lesion with IVUS and tight stenosis with encircling calcification was confirmed (Figure 2). Considering heavy calcification, we decided to perform rotablation. Then, a 0.014 inch Rotawire was placed into the LAD. Based on IVUS and angiography image, we performed with a rotablator 1.25mm burr and 1.5mm burr (Figure 3). After rotablation, we changed a 0.014 inch Rotawire into a 0.014 inch BMW wire at LAD. Pre-dilatation at pmLAD with a NC TREK balloon 2.5x2.0mm was performed (Figure 4). After pre-dilatation, we deployed the PROMUS Premier stent 3.0x28mm at mLAD (Figure 5), PROMUS Premier stent 3.5x24mm at pmLAD (Figure 6) and PROMUS Premier stent 4.0x24mm at LM-pLAD (Figure 7). Post-stenting adjunctive balloon dilatation with Quantum balloon 3.5x20mm, and 4.0x20mm was performed (Figure 8). Final angiogram showed that the procedure was successful ( Movie 2).

Comments

  • Jae Hong Park 2016-09-06 well, I am so happy to see the tough case and standard method. Do you condiser the stent size step down from LM to mLAD? maybe 2.75mm diameter stent at mLAD was started and 3.5mm diameter stent at LM was ended up, and so on. I think safe selection of stent size because we prepare the additional ballooning after stent deployment. thanks for the brilliant case through on-line website.
  • Se Hun Kang 2016-09-06 Thank you for comment. As you mentioned stent selection of smaller diameter could be a good and safe choice. Although images were not shown in presentation, IVUS was re-checked after rota-ablation. IVUS showed a break of encircling calcification and vessel diameter was also checked again. From these measurements, we could choose bigger stent compared to selection of stent diameter based on angiography alone.

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