Case Presentation: Navigating Strategies in Uncrossable High Risk Complex Lesions: Synergistic Solutions Integrating Shockwave IVL with Atherectomy for Optimizing Outcomes
Presenter
DineshReddy Apala, MD, Baylor Scott and White Heart Hospital Plano, Mckinney, TX
DineshReddy Apala, MD, Baylor Scott and White Heart Hospital Plano, Mckinney, TX
Keywords: Atherectomy, Complex and High-risk Coronary Intervention (CHIP), Coronary, Drug-eluting Stent (DES) and Intravascular Lithotripsy (IVL)
Title:
Navigating Strategies in Uncrossable High Risk Complex Lesions: Synergistic Solutions Integrating Shockwave IVL with Atherectomy for Optimizing Outcomes Introduction:
Percutaneous coronary intervention (PCI) offers revascularization for complex lesions. However, heavily calcified and chronically occluded lesions pose significant challenges for crossing and optimal outcomes. This presentation details a complex case integrating rotational atherectomy and shockwave intravascular lithoplasty (IVL) to achieve successful revascularization. Clinical Case:
An 81-year-old woman with peripheral arterial disease (PAD) status post right femoropopliteal bypass presented with unstable angina. Patient was transferred for PCI of a heavily calcified critical ostial and mid right coronary artery (RCA) stenoses (99%) which was diagnosed by coronary angiography at outside hosital. Due to lesion complexity, she was transferred for high-risk PCI. LVEF of 35-40% by Echocardiography. The right radial arterial access approach was utilized. Initial attempts to cross the lesion using workhorse wire was unsuccessful. After multiple attempts, we were successfully able to cross using Fielder XT guidewire with wire escalation strategy. We had difficulty and were not able to advance any balloons, hence deemed to be a balloon uncrossable lesion. Hence, we decided to proceed with lesion modification strategy using rotational atherectomy. But we were not able to advance any microcatheter for exchanging the existing guide wire to Rota floppy wire. Hence, we had to risk losing guidewire access to the lesion with microcatheter positioned proximal to the lesion. However, we were able to rewire the lesion using Rota floppy wire which was a crucial step in performing the PCI. We then performed rotational atherectomy which enabled us to perform shockwave intravascular lithotripsy for adequate lesion preparation and facilitated stent expansion. IVUS guidance was used for lesion preparation, reference vessel sizing and stent optimization. The post-PCI angiographic results were excellent, underscoring the efficacy of the synergistic approach. Discussion:
This case demonstrates the successful management of a complex coronary lesion using a combined approach of rotational atherectomy and shockwave IVL. It also highlights the importance of addressing challenging and utilizing strategies to navigate balloon uncrossable and microcatheter uncrossed complex lesions. By carefully selecting devices and planning for potential contingencies, operators can optimize outcomes for patients with challenging coronary artery disease. The key takeaways from this case are: - Atherectomy device selection: Utilizing atherectomy devices like Rotational, orbital atherectomy, or laser atherectomy in appropriate settings can facilitate crossing complex lesions.
- Wire choice planning: Strategic planning with wire choices is crucial to mitigate the risk of losing wire access, which could lead to catastrophic outcomes.
- Shockwave IVL for complex lesions: Shockwave IVL can be a valuable tool for modifying heavily calcified lesions alongside atherectomy techniques.
- Complementary approach: Integration of Shockwave IVL with other atherectomy modalities enhances efficacy in managing complex calcified coronary lesions.
- IVUS/OCT guidance: Incorporating intravascular imaging guidance such as IVUS/OCT aids in optimizing procedural decision-making and outcomes.
In conclusion, navigating uncrossable high-risk complex lesions demands a multifaceted approach integrating advanced technologies and strategic planning, with the aim of achieving optimal results in challenging PCI cases.