Cut, Score, Drill, or Shock? The Calcified Nodule Conundrum: Serial Intravascular Imaging Assessment in a Case of Ostial RCA In-stent Restenosis
William Lang, MD, The University of Vermont Medical Center, Burlington, VT
William Lang, MD1, Joshua Zimmer, MD1, Anand M Muthu Krishnan, MBBS1 and Tanush Gupta, MD2, (1)The University of Vermont Medical Center, Burlington, VT, (2)The University of Vermont Medical Center, South Burlington, VT
Title:
Cut, Score, Drill, or Shock? The Calcified Nodule Conundrum: Serial Intravascular Imaging Assessment in a Case of Ostial RCA In-stent Restenosis
Introduction:
Percutaneous coronary intervention (PCI) of calcific nodules (CN) poses a clinical challenge, with high rates of vessel restenosis and clinical ischemic events despite acceptable initial acute luminal area gain. We describe a case of complex PCI of an ostial right coronary artery calcific nodule that required multimodality intravascular imaging and advanced lesion modification techniques.
Clinical Case:
A 70-year-old man with history of hypertension and hyperlipidemia with progressive angina (Canadian Cardiovascular Society Class IV) despite medical therapy presented for elective left heart catheterization. Diagnostic coronary angiography revealed a 99% stenosis in the ostial RCA with TIMI-2 flow. There was concomitant intermediate left main (LM) and proximal left anterior descending artery (LAD) disease. LM and LAD disease was assessed with intracoronary physiology and diastolic hyperemia-free ratio (DFR) was 0.9. Intravascular ultrasound (IVUS) of the LM showed a plaque burden of 30% and a minimal luminal area (MLA) of 13 mm2. Decision was made to proceed with PCI of the RCA. After pre-dilation with 2.5 mm semi-compliant balloon, IVUS showed a large calcific nodule with a 120-degree arc in the ostial RCA. Lesion modification was performed with a 3.5 mm Angiosculpt balloon. Repeat IVUS imaging showed multiple calcium fractures. There was severe plaque burden extending into the mid RCA. Three overlapping stents were placed from the ostial to mid RCA (4.0 x 38 mm, 4.0 x 23 mm, 4.0 x 28 mm drug eluting stents (DES)) followed by high-pressure post dilation with a 4.0 mm non-compliant (NC) balloon with complete stent expansion and final excellent angiographic results. Repeat coronary angiography six months later for recurrent angina symptoms showed 80% in stent-restenosis in the proximal RCA. IVUS imaging showed significant in-stent restenosis with protruding CN through the stent struts. Intravascular lithotripsy was performed with a 4.0 x 12 mm Shockwave C2 balloon. Adjunctive pre-treatment was performed with a 4.0 mm Wolverine cutting balloon. A 4.0 x 15 mm Onyx DES was then deployed in the RCA ostium and post-dilated with a 4.25 mm NC balloon followed by a 5.0 mm ostial flash balloon. Final optimal coherence tomography showed a minimal stent area of 10.66 mm
2 and an excellent angiographic result.
Discussion:
Despite best attempts at lesion preparation and stent expansion, nodular re-protrusion and target lesion failure can occur. Our case illustrates the complexities in percutaneous management of CNs despite the use of modern PCI techniques.