2022 Scientific Sessions

Title

Rota to the Rescue

Introduction

While most ST elevation myocardial infarctions involve the rupture of soft plaque, up to 40% of ACS involve moderate to severe calcified lesions. While rotational atherectomy is considered an off-label use in coronary arteries with thrombus, we present a case of a late presenting inferior STEMI that was complicated by a severely calcified artery with a balloon un-crossable lesion which required aggressive rotational atherectomy for plaque modification and successful revascularization.

Clinical Case

An 86 year old white female with past medical history of GERD and hypothyroidism presented to an outlying facility for chest discomfort and nausea that had started more than 24 hours prior. On arrival, her EKG showed ST elevations in the inferior leads. She was transferred to our facility for urgent left heart catheterization. On arrival to our facility, she was having persistent chest pain and was taken urgently to the lab. LHC revealed a severely calcified 99% stenotic lesion in the proximal and mid RCA. An AL 0.75 guiding catheter was used to engage the RCA but there was difficulty crossing the lesion with a workhorse guide wire (Sion Blue). Eventually, the lesion was crossed with a tapered tip polymer jacketed guidewire (Fielder XT-A) with microcatherer support (Mamba Flex). There was difficulty crossing the lesion despite use of multiple low profile balloons (Takeru). With great difficulty, another microcatheter (Corsair Pro Xs) crossed the lesion. Given the difficulty or crossing, the decision to debulk the lesion with rotational atherectomy was made despite a warning from the manufacturer (Boston Scientific) regarding their use in presence of thrombus. Multiple runs of rotational atherectomy were performed and eventually after aggressive de-bulking and subsequent aspiration thrombectomy followed by high pressure angioplasty, the lesion was able to be modified successfully. Finally, IVUS-guided PCI was completed by placement of 4.0 x 38mm and 4.5 x 32mm everolimus eluting platinum chromium stents. The patient tolerated the procedure well.

Discussion:

In the setting of a STEMI, balloon un-crossable lesions are uncommon. Rotational atherectomy is a proven plaque modification technique for heavily calcified lesions that are not able to be modified with balloon angioplasty alone. It carries a class IIa recommendation by ACC/AHA guidelines for heavily calcified lesions. Rotational atherectomy use in STEMI is controversial, however. Presence of thrombus is listed by the manufacturers as a contraindication for use as it increases the risk of distal embolization causing no reflow. Pooled analysis has shown (HORIZONS-AMI, ACUITY) acute coronary syndrome occurs frequently in severely calcified vessels, which can increase risk of complications (perforation with high pressure balloons, damage to the drug-coated layer of the stent, risk of stent under-expansion, malapposition and compromise long term patency). When one encounters a balloon un-crossable lesion, even in the setting of STEMI, more invasive plaque modification techniques must be employed to restore normal coronary flow and optimize stent placement and patency. Early consideration of off-label plaque modification techniques can be considered to optimize outcomes in patients who present with complex, severely calcified, balloon un=crossable lesions in ACS.