2024 Scientific Sessions

Title:

Bailout Use of Rotational Atherectomy in inferior STEMI

Introduction:

The presence of coronary artery calcification represents a major challenge during re-vascularization and is associated with worse outcomes after percutaneous coronary interventions. Although, a successful tool for calcium modification, the use of Rotablator rotational atherectomy (RA) in cases of ST elevation myocardial infarction (STEMI) has been labelled a relative contraindication by the device manufacturer due to concerns for procedural complications. We present a case of inferior STEMI secondary to an ulcerated and calcified proximal to mid RCA lesion necessitating use of RA in a factor V Leiden (FVL) heterozygous female with excellent angiographic results.

Clinical Case:

An 82-year-old female with heterozygous FVL mutation presented to the emergency department with acute left sided chest pain and was found to have inferior STEMI. She was emergently taken to the cardiac catheterization lab where a coronary angiogram revealed an ulcerated and calcified lesion in the proximal to mid RCA. The lesion was wired and pre-dilatation was performed with a 2.5x12 mm balloon. Further pre-dilatation was attempted with 2.5x12 mm non-compliant balloon. However, the balloon appeared underexpanded, and subsequently ruptured. We then attempted to treat the lesion using intravascular lithotripsy. However, a 3.0 mm Shockwave balloon could not be advanced past the target lesion. We then performed RA with a 1.5 mm burr (4 passes). This allowed successful pre-dilatation of the lesion with the non-compliant balloon and eventual placement of overlapping 3.0x38 mm and 3.5x15 mm drug eluting stents. The final angiography result was excellent, with TIMI-3 flow in the RCA territory.

Discussion:

Pooled analysis from HORIZONS-AMI and ACUITY trials demonstrates high prevalence of moderate or severe lesion calcification in STEMI (54.6% and 63.7% respectively), and is strongly predictive of stent thrombosis and ischemic target lesion revascularization at one year. With an ageing population and underlying co-morbidities including diabetes mellitus and chronic kidney disease, the frequency of encountering calcific vasculature in ACS remains high. Despite its well-established use in calcific stable CAD, the role of RA in thrombo-calcific ACS remains controversial. RA is generally avoided in high thrombotic states such as STEMI due to the risk of further platelet activation by the rotablater and the higher risk of slow or no-reflow. However, in cases of non-dilatable and balloon un-crossable lesions, the use of RA allows sufficient lesion morphology alteration to allow other devices to be used. Patient with STEMI with heavily calcified culprit lesion requiring RA represent a high risk population frequently presenting with cardiogenic shock (CS). Based on results from Multicenter ROTA-STEMI network, RA performed as part of bailout strategy in ACS seemed to be a feasible option with high procedural success rate and a low in-hospital mortality (in cases without CS). Hence, the use of RA should be considered on a case to case basis particularly with heavily calcified culprit lesions in cases of STEMI for optimal plaque modification and revascularization.