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Rotational atherectomy for severe, heavily calcified, undilatable lesion intervention
- Operator: Seung-Jung Park, MD
Relevant clinical history and physical exam

A 69 year-old gentleman visited our hospital because of recurrent chest pain. He underwent coronary intervention with Driver 3.5x24mm at proximal LAD in another hospital, 1 month ago. After intervention, he suffered from persistent, effort-related angina. So he visited our lab because of secondary opinion. We checked angiograms of procedure which was performed at another hospital, meticulously. His coronary risk factors were hypertension, dyslipidemia, and diabetes.

Relevant catheterization findings

Left coronary angiogram showed severe stenosis at previous stented area. The meticulous analysis of image showed unsuccessful, underexpansion of previous stent with severe calcification. (Figure 1, Figure 2, Figure 3).

Procedural step

Lt. JL4 SH 8Fr guiding catheter was used for intervention. After wiring with conventional 0.014 inch wire, firstly we tried to check IVUS. But IVUS catheter was broken because of severe stenosis. We tried again and succeeded. We check IVUS cautiously. IVUS showed relatively large vessel size but heavy, encircling calcification. And there was some stent inapposition and narrow lumen with encircling stent strut due to calcified, un-dilatable lesion. (IVUS Figure 1, IVUS Figure 2)

After medical records review, we knew that high-pressure ballooning with non-compliant balloon was unsuccessful at another hospital. We firstly tried to use rotation atherectomy. Using Finecross 1.8Fr microcatheter, the wire was changed to the 325cm 0.014 inch Rota wire. We begun with a 1.5-mm burr, successfully for three times ( Movie 1) and stepped up to 1.75-mm burr size. But the excessive burr deceleration occurred. We changed another, new 1.75-mm burr but also occurred. The burr was entrapped at the lesion. We decided to use non-complaint balloon dilatation because we thought some lesion modification was successfully made by rotablation. We performed gradual step-up high pressure ballooning with non-complaint balloon such as Dura-Star 2.5x20 mm upto 30 atm, Dura-Star 3.0x20 mm upto 30 atm and Quantum 3.5x15 mm upto 25 atm (Figure 4, Figure 5, Figure 6). Angiogram showed significantly improvement of stenosis. (Figure 7) A follow-up IVUS showed some stent malformation with modification of calcium lesion. (IVUS Figure 3, IVUS Figure 4) One more pre-stenting balloon dilation with Quantum 3.5x15 mm was performed. (Figure 8) A 3.5x33 mm sized Cypher-select stent was deployed for whole lesion coverage. (Figure 9) After stenting, post-stent adjunctive ballooning with Dura-Star 3.5x15 mm upto 28 atm was performed. (Figure 10, Figure 11) Final angiogram showed successful, well-optimized stent deployment. (Figure 12)

Alberto Hendler2010-02-21
Is this a case of in stent restenosis ?????
Jong-Young Lee2010-02-23
No, this case was not in-stent restenosis lesion. About 1 month ago, patient received PCI at LAD in another hospital. The chest pain was persistent even after PCI. So we reviewed angiogram of procedure at another hospital. The final angiogram showed suboptimal expansion of stent. and the calcium lesion was not dilated even after non-compliant balloon dilation. So this lesion was a originally underexpanded stent lesion of BMS.
riza hakiki2010-07-26
WHAT ARE THE RİSKS OF ROTATİONAL ATHERCTOMY PROCEDURE İNSİDE A UNDER EXPANDED OR NOT ENDOTHELİZED STENTS?
what did you do when the burr was entrapped to get the burr out
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