Case

Rotablating Atherectomy for Treatment of Unexpanded Stent at Heavily Calcified Lesion

- Operator : Seung-Jung Park

Rotablating Atherectomy for Treatment of Unexpanded Stent at Heavily Calcified Lesion

- Operator: Seung-Jung Park, MD
Patient presentation

A 55 year old man was admitted with effort angina for 3 months. He had diabetes mellitus and hypertension for coronary risk factors. Baseline coronary angiogram (CAG) showed three-vessel disease. After stenting in the left anterior descending and circumflex arteries with Cypher stents, we tackled the proximal right coronary artery (RCA) lesion.

Procedure

Right coronary ostium was engaged with an 8Fr AL2 guiding catheter. The CAG showed diffuse calcified narrowing of the proximal RCA (Image 1). The lesion was predilated with a Black-Hawk balloon (2.5 x 20 mm). Fluoroscopic indentation at the center of balloon was not relieved at 20 atm (Image 2). In spite of the residual indentation, we intended to put a stent because the lesion did not look serious. So, a Cypher stent (3.5 x 28 mm) was deployed at the lesion (Image 3), but unexpanded (Image 4). We tried repeated high pressure balloon dilatations with a non-compliant Quantum balloon (2.5 x 8 mm) up to 30 atm (Image 5). However, the stent was not dilated due to the heavy calcification (Image 6). Therefore, we performed rotablating atherectomy as a rescue procedure using 1.5 and 2.5 mm burrs (Image 7). Following angiogram showed slightly widened lumen (Image 8). IVUS showed discontinuation of the grinded stent strut (Movie 1). Then, another Cypher stent (3.5 x 13 mm) was deployed at the bared site with following high pressure balloon dilatation with a Maverick balloon (3.0 x 12 mm) at 20 atm (3.6 mm) (Image 9). The final angiogram showed a successful result (Image 10).

Comments

  • Woong Chol Kang 2005-11-05 We had a similar case like this. After stent implantation, there wes unexpanded area at mid stent area. IVUS examination revealed encircling calcified ring around lesion. So we performed post stent dilatation with small diameter cutting balloon. And then we changed larger size cutting balloon. After several times dilatation with upsizing cutting balloon, we could get a optimal result. After procedure, IVUS examination revealed destroyed calcified circula ring by blade of cutting balloon.
  • AVZOTIS DIMITRIS 2005-11-09
  • Rosli Mohd Ali 2005-11-09 We had a case presented during our morbidity and mortality meeting of a similar case whereby the patient developed subacute stent thrombosis 3 days after the procedure. This case and the above illustrates the importance of getting a good stent deployment especially with a drug-eluting stent. We generally will upsize with a 3.0 and subsequently 3.5 mm non-compliant balloon at very high pressures.
  • Bong-Ki Lee 2005-11-10 High pressure dilatation may be useful in such cases. However, it did not work in this case. From our case, we would like to show the messages that 1) the lesion is not always simple as it looks, 2) predilatation is a very important step in a severly calcified lesion, and 3) rotablation is a resonable approach as a pre-treatment or a post-treatment in undilated lesions.
  • Joy M. Thomas 2005-11-14 Excellent result. How was the microvascular flow and myocardial blush after the procedure? I would have done cutting balloon after the failure of high pressure dilatation and the did the stenting later.
  • Marcelo Ribeiro 2006-01-07 This is probably one of the three current best sites of interventional cardiology , so I thank you for the quality of everything.The main point in this case is do not try to put a stent on an undilatable lesion .As have been mentioned before ,now we have got the cutting balloon and the rotablator to do the work before to finish off with the stent.
  • yan yan 2007-07-31 It's so ridiculous to put in the first stent!

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