Title - When Rotational Atherectomy is not Enough
Short Title - Extreme Coronary Calcification
Negar Atefi1, Basem Elbarouni1,2,
Amir Ravandi1,2, David W Allen1,2
1 Max Rady College of Medicine, University of Manitoba
727 McDermot Avenue, Winnipeg MB, CAN R3E 3P5
2St Boniface General Hospital, Section of Cardiology
409 Tache Avenue, Winnipeg, MB, CAN R2H 2A6
Corresponding Author:
David W Allen MD FRCPC
Assistant Professor
Section of Cardiology,
Max Rady College of Medicine, University of Manitoba, Canada
409 Tache Avenue, RmY3543
Winnipeg, Manitoba, Canada
R2H 2A6
Ph 204-237-2390 Fax 204-233-4853
dallen@sbgh.mb.ca
Conflicts: None
Word Count 1505 (including references)
Key words: Cardiovascular disorders
Key Clinical Message: Extreme coronary calcification may
require rotational atherectomy to create a navigable intravascular lumen
followed by intravascular lithotripsy to fracture areas of deep
calcification to allow for successful percutaneous coronary
intervention.
Abstract
Severe coronary calcification predicts stent under-expansion,
malapposition, and poor outcomes in percutaneous coronary intervention.
Rotational atherectomy permits debulking of coronary calcium allowing
for stent expansion. More recently, intravascular lithotripsy has been
used to fracture calcium and aid revascularization. Here we report two
cases where both strategies were required for revascularization.
Introduction
Calcified coronary lesions are more likely to result in stent
malapposition and expansion resulting in higher rates of restenosis,
thrombosis, and myocardial infarction (1). In this patient population,
fastidious lesion preparation is critical to ensure that calcium
fracture is sufficient to allow for stent expansion. Commonly used tools
include non-compliant (NC) balloons, cutting balloons, scoring balloons
and atherectomy. Recently, intravascular lithotripsy (IVL) has been used
for recalcitrant lesions and may supplant atherectomy owing to its ease
of use, risk profile and long-term risk profile (2). Atherectomy on the
other hand, is best reserved for specialized, high-volume centers.
However, even in these settings, atherectomy is a time consuming and
costly procedure associated with an increased risk of procedural
complications (2,3). However, IVL is only effective if it can be
delivered to the site of coronary calcification. Thus, atherectomy and
IVL may not be mutually exclusive techniques, some lesions require
atherectomy to gain intimal passage for IVL to fracture deeper layers of
calcium for successful revascularization (4,5).
Case 1:
A 68-year-old male with a history of coronary artery disease with
previous PCI to the right coronary artery, diabetes mellitus,
hypertension, dyslipidemia, and gout presented with chest pain and was
diagnosed with a non-ST elevation myocardial infarction (NSTEMI).
Angiogram identified a severe mid-LAD calcified lesion (Figure 1.A).
Balloon angioplasty was performed with compliant and NC balloons with
failure to yield (Figure 1.B). Therefore, the procedure was stopped, and
the patient returned for dedicated atherectomy. A 7French radial system
was used to perform rotational atherectomy with a 1.75mm and a 2.0mm
burr. Despite this, the lesion would not yield in spite of high-pressure
balloon inflation after each run (Figure 1.C and 2.E). Optical Coherence
Tomography (OCT) was performed after each attempt and confirmed the
presence of a 1.75mm and 2.0mm lumen surrounded by dense circumferential
calcification (Figure 1.D and 2.F). Therefore, intravascular lithotripsy
(Shockwave Medical, Santa Clara, CA, USA) was performed. A 3.5mm
shockwave IVL balloon was delivered and 8 rounds of lithotripsy were
performed. Subsequent OCT confirmed multiple fractures within the lesion
(Figure 1.G). A Promus Premier (Boston Scientific, Marlborough, MA, USA)
3.5x32mm drug-eluting stent was delivered and post-dilated using a
4.0x20mm NC balloon proximally and a 3.75mm NC balloon distally with
excellent results (Figure 1.H).
Case 2:
A 79-year-old male with a prior history of PCI to the proximal LAD
presented with NSTEMI and was referred for coronary angiography. The
culprit lesion was proximal LAD with total occlusive in-stent restenosis
(ISR) (Figure 2.A). Successful antegrade wiring of the occlusion was
performed. Despite multiple NC balloons and cutting balloons, the lesion
remained resistant to expansion (Figure 2.B). Intravascular ultrasound
(IVUS) confirmed highly calcified lesion within the previous stent.
Atherectomy was performed using a 1.5mm and a 2.0mm burr. However, the
lesion was resistant to expansion with NC and cutting balloons (Figure
2.C and 2.D). A distal dissection developed and was stented with a
2.5x28mm Promus Premier drug-eluting stent (Figure 2.E). At this point,
the procedure was stopped and the patient brought back for IVL. IVL was
performed using a 3.5mm Shockwave balloon for 6 cycles. This allowed for
successful pre-dilatation of the calcified lesion with a 4.0mm NC
balloon at high pressure. This allowed the placement of a 4.0x24mm
Promus Premier drug-eluting stent to be placed with excellent results
(Figure 2.G).
Discussion
The cases discussed above demonstrate that even large burr rotational
atherectomy in heavily calcified lesions may not sufficiently prepare
the lesion for expansion. In both cases multiple rounds of atherectomy
were attempted after the failure of traditional lesion preparation
techniques. IVL was not initially attempted as the imaging and
introduction of smaller devices demonstrated that the IVL balloon could
not be delivered to the lesion. Atherectomy was required to develop an
accessible lumen, but was not sufficient to fracture the dense
circumferential calcification. In both cases, intravascular imaging was
critical to identification of the true vessel size and the burden of
calcification resulting in use of IVL to fracture the residual lesion.
The Disrupt CAD I and II studies have demonstrated that IVL is
particularly suited for lesions with circumferential calcification; it
results in multiple planes of fracture and is not prone to wire bias, a
known limitation of atherectomy (3,6). These studies also demonstrated a
favorable procedural complication rate and good longer-term outcomes.
Therefore, IVL and rotational atherectomy can be complementary to one
another and may occasionally be used in combination to provide better
results in patients with severely calcific lesions (7). Rotablation
ablates calcium in the intima and allows for an accessible passage for
balloons and stents, IVL utilizes this passage and treats the
circumferential deep calcium layers of the lesion. Proficiency in both
techniques is required when handling lesions of this subset.
Conclusion
Extreme calcification may require atherectomy and IVL to achieve optimal
revascularization results and interventional cardiologists should be
familiar with the use and limitations of each technique.
Acknowledgements
None.
Conflict of Interest
No funding or conflict of interest to disclose for Mrs Atefi, Dr’s
Elbarouni, Ravandi or Allen.
Author contributions
NA wrote the manuscript, DWA & BE contributed the presented cases. AR
and DWA contributed to the design and critically reviewed and revised
the manuscript.
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Figure 1. (A) Pre-procedure angiogram of mLAD lesion(arrow) in anterior-posterior (AP) cranial view. (B)Failure to expand with a 3.5mm NC balloon to high pressure(arrows) . (C) Failure to expand with a 3.5mm NC
balloon after rotational atherectomy with a 1.75mm burr(arrows) (D) OCT post 1.75mm bur rotational
atherectomy confirming formation of a 1.73mm diameter lumen.(E) Failure to expand with a 3.5mm NC balloon to high pressure
(arrow) after 2.0mm burr rotational atherectomy and (F) Repeat
OCT confirming 2.0mm lumen with dense calcification (G) OCT
image post-IVL demonstrating fractures in the lesion. (H)Post-PCI angiogram showing successful revascularization in mLAD