Title
Severely calcified multi vessel coronary intervention with rotational atherectomy and intravascular lithotrypsy.
Introduction
With increasing use of coronary computed tomography and intravascular imaging, detection of coronary calcification is growing. Calcified coronary lesions are more prevalent among patients with chronic kidney disease, type II diabetes mellitus, advanced age, systemic hypertension, and dyslipidemia. Percutaneous coronary intervention (PCI) of calcified lesions presents multiple challenges with wiring, balloon/stent delivery, optimal expansion and outcomes. Several strategies have been formulated to address each challenge. These approach comes with their shares of increased risk of complications, anticipating and being prepared for them will pertinent while performing high risk PCI of calcified lesions. Clinical Case
67 year old male with hypertension, hyperlipidemia, alcohol abuse, tobacco abuse with recent hospitalization for Non ST elevation myocardial infarction (NSTEMI), underwent left heart catheterization and noted Proximal left anterior descending artery (LAD) 70%, Mid LAD 90%, Proximal Diagonal 1 (D1) 80%, Mid Left Circumflex artery (LCX) 99%, Proximal Right coronary artery(RCA) 90%. Upon evaluation determined not a surgical candidate. Initially managed medically but patient continued to have angina (CCS 2) and shortness of breath (NYHA 3). He was referred for high risk PCI.
Upon evaluation of the angiographic images, decision made to intervene on LAD and LCX; staging RCA later. We anticipated difficulty crossing and delivering balloons/stents across and hence planned to perform rotational atherectomy. Successful rotational atherectomy of LCX and LAD, intravascular lithrotrypsy (IVL) of LAD and D1 with 1:1 sizing of IVL and NC balloon was performed. Successful deployment of stent in LCX and performed bifurcation stenting of mid LAD and D1 by double kissing (DK) crush technique. Proximal LAD stent was deployed overlapping with mid LAD stent. Post stent deployment, noted coronary perforation with extravasation in angiographic images. Balloon tamponade with 1:1 size NC balloon of LAD for 3 minutes in total with 30 second deflation for every 1 minute interval and reversal of anticoagulation with protamine was performed. Final angiographic images noted excellent Thrombolysis in Myocardial Infarction (TIMI) 3 flow and no significant extravasation concerning for perforation.
Discussion
With the introduction of novel technologies like intravascular coronary imaging, computed tomography - fractional flow reserve (CT-FFR) and instantaneous fractional reserve (IFR), Coronary artery disease (CAD) are being diagnosed early and medically managed, if the lesions are not hemodynamically significant. This will lead to interventional cardiologists seeing patients who are older, with multiple co-morbidities and complex coronary lesions. Severely calcified lesions particularly presents a significant challenge during the procedure and with outcomes. Choosing an effective debulking method helps with effective stent delivery and deployment. Using coronary imaging to assist will increase chance of achieving optimal luminal gain. Providers should also be knowledgable about various complications while performing high risk PCI and be prepared to reduce adverse outcomes during the procedure.