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Severe Calcified Chronic Total Obstruction Treated by Rotablation
- Operator: Seung-Whan Lee, MD
Case Presentation
A 80-year-old male patient was admitted for dyspnea on exertion. He underwent PCI at the mid LAD 17 years ago for STEMI and PCI at proximal to mid LAD 11 years ago for stable angina. The SPECT showed partially reversible large-sized severe perfusion defect in apical-mid anterior, apical septal, mid-basal anteroseptal, apical inferior wall. Her coronary angiography demonstrated total occlusion of proximal to mid LAD stent (ISR), left main 70% dffuse stenosis and proximal to mid RCA diffuse 80-90% stenosis. Her coronary arterial risk factor was dyslipidemia. His electrocardiogram showed normal sinus rhythm. Echocardiography revealed mild left ventricular systolic dysfunction with akinesia of LV apex, mid anterior septum and basal inferior wall.
Baseline Coronary Angiogram
  1. The right coronary angiogram showed proximal to mid RCA diffuse 80-90% stenosis ( Movie 1).
  2. The left coronary angiogram showed LV 70% diffuse stenosis and proxima to mid LAD stent ISR CTO lesion ( Movie 2, Movie 3).
Procedure
An 7 Fr long sheath was inserted through the left femoral artery and the left coronary artery was engaged with a 7 Fr XB 3.5 guiding catheter. A corsair 2.6 Fr-135 cm micro-guide catheter with a 0.014-inch ASAHI Sion wire successfully passed through the lesion. Balloon dilatation was performed with FLUYDO 2.5 x 15 mm at the proximal-to mid LAD. We checked IVUS of the lesion after pre ballooning. We decided to use Angiosculpt 3.0X15mm due to the heavily calcified lesion ( Movie 4). Angiosculpt 3.0 X 15mm was inflated upto 18 atm (3.5mm) at proximal to mid LAD ISR lesion. Orsiro stent 4.0X15mm was implanted at LM to proximal LAD upto 14 atm (4.33mm) with overlap of previous stent ( Movie 5). Subsequently, drug coated balloon was inflated at proximal to mid LAD ISR lesion for 30 seconds ( Movie 6). After stenting and POBA, we checked IVUS of the lesion. The final angiogram showed successful results ( Movie 7).

Appendix
LAD IVUS image of post ballooning ( Movie 8)
LAD IVUS image after stenting and POBA (Final IVUS image) ( Movie 9)
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