Severe Calcified Chronic Total Obstruction Treated by Rotablation

- Operator : Pil Hyung Lee

Severe Calcified Chronic Total Obstruction Treated by Rotablation
- Operator: Pil Hyung Lee, MD
Case Presentation
A 63-year-old male patient was admitted for PCI for RCA CTO lesion.
She underwent coronary angiography due to thallium-SPECT abnormality, which was performed for dyspnea on exertion. She underwent PCI at the mid-distal LAD 15 years ago. The SPECT showed partially reversible medium-sized severe perfusion defect in mid-basal inferior wall and moderate perfusion defect in apical-mid anterior wall. Her coronary angiography demonstrated total occlusion of mid RCA with heavy calcification and discrete narrowing of the previous stent at the mid-distal LAD.
Her coronary arterial risk factors were hypertension and diabetes mellitus. Her electrocardiogram showed atrial fibrillation. Echocardiography revealed mild left ventricular systolic dysfunction with akinesia of basal inferior and basal septum, hypokinesia of mid to basal posterior and mid inferior wall.
Baseline Coronary Angiogram
  1. The right coronary angiogram showed chronic total occlusion at mid RCA with heavy calcification ( Movie 1).
  2. The left coronary angiogram showed discreate in-stent restenosis at mid to distal LAD stent ( Movie 2, Movie 3).
Procedure
An 8 Fr long sheath was inserted through the right femoral artery and the right coronary artery was engaged with a 7 Fr AL 2 guiding catheter. A corsair 2.6 Fr-135 cm micro-guide catheter with a 0.014-inch ASAHI Sion, Gaia 2 wire failed to pass the CTO lesion. Subsequent attempts with a Caravel 2.6 Fr - 135 cm micro-guide catheter with ASAHI Fielder XT, Fielder XT-A wires were also failed. Finally, Caravel micro-guide catheter with Gaia 2 wire successfully passed through the lesion. Balloon dilatation was performed with Tazuna 2.5 x 15 mm, 2.0 x 15 mm at the proximal-to distal RCA ( Movie 4). After several attempts, guidewire was placed at the PL branch. We decided to perform rotablation due to the heavily calcified lesion. A 0.014 inch rotawire was inserted through the RCA and a temporary pacemaker was inserted for the back-up pacing during rotablation ( Movie 5). Then, stepwise rotablation was done with 1.25 mm burr at the calcified RCA lesion ( Movie 6, Movie 7). Subsequently, additional balloon dilatation was performed with Tazuna 2.0 x 15 mm, 2.5 x 15 mm, NC TREK 3.0 x 20 mm balloon at the proximal-to distal RCA. After rotablation, IVUS was checked at the RCA. Xience Alpine 4.0 x 38 mm, 4.0 x 33 mm stent were implanted at the proximal-to mid RCA with extra back-up support using the Guide zilla 6Fr ( Movie 8, Movie 9, Movie 10), and subsequent high pressure ballooning was performed with Sapphire NC 4.0 x 15 mm at pmRCA and Tazuna 2.5 x 15 mm at mRCA ( Movie 11, Movie 12). Additional POBA was performed with Tazuna 2.5 x 15 mm at dRCA ( Movie 13). The final angiogram showed successful results ( Movie 14).

Appendix
RCA IVUS image of pre-rotablation ( Movie 15)
RCA IVUS image of post high-pressure balloon (Final IVUS image) ( Movie 16)

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