Left Main and Diffuse Long LAD Lesion with Heavy Calcification Treated by Rotational Atherectomy

- Operator : Seung-Jung Park

Left Main and Diffuse Long LAD Lesion with Heavy Calcification Treated by Rotational Atherectomy
- Operators: Seung-Jung Park, MD, Young-Hak Kim, MD
Case Presentation
A 66-year old gentleman was referred to our hospital for the LM PCI. About two weeks ago, he experienced an effort-related chest pain, and his coronary angiogram demonstrated severe stenosis with heavy calcifications at LM to proximal LAD. His coronary risk factors were hypertension, diabetes mellitus, and ex-smoking. The echocardiography showed normal LV systolic function (EF=62%) without RWMA. Thallium SPECT showed reversible large sized perfusion defects at LAD and LCX territories. Syntax score was 23.
Baseline Coronary Angiogram
1. The left coronary angiogram showed severe stenosis with heavy calcifications at LM to proximal LAD. ( Movie 1, Movie 2)
2. The right coronary angiogram showed intermediate stenosis at PDA.( Movie 3)
Procedure
A 8 Fr JL4 guiding catheter with side hole was engaged into left coronary artery through right femoral approach. Two 0.014 inch BMW wires were placed into the LAD and LCX, respectively. We performed IVUS examination to take accurate information, especially for the LCX ostium. In IVUS, distal LM was very tight stenosis with heavy, encircling calcification, but LCX ostium was relatively preserved. Therefore, we decided to use rotational atherectomy at distal LM and LAD lesion and simple crossover strategy. we exchanged into a 0.014 inch 325cm Rota wire and performed rotational atherectomy with a 1.5-mm burr for two times. After Rota ablation, we exchanged Rota wire for longer 0.014 inch BMW wire (300 cm) and tried to dilate distal LM with IKAZUCHI 1.5 * 20 mm and Fortis 2.75 * 18mm. But the distal LM lesion was not appropriate dilated. So, we decided to use of cutting balloon (2.75 * 10 mm) (Figure 1). After dilated with cutting balloon, Predilation was performed using Fortis 2.75 * 18 mm and Trek 2.0 * 20 mm at proximal to middle LAD. Then, we deployed the Xience Prime stent 3.0 * 38 mm at LM to proximal LAD and Xience Prime stent 2.75 * 23 mm at proximal LAD to middle LAD (Figure 2). Post-stenting adjunctive balloon dilatation was performed at LM to proximal LAD with a Quantum 3.0 * 15 mm and Fortis 3.5 * 18 mm (Figure 3). Final angiogram showed that the procedure was successful ( Movie 4, Movie 5).

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