Case

Severely Calcified ISR Lesions of LAD Bifurcation Treated by Rotablation

- Operator : Paul Hsien-Li Kao

Severely Calcified ISR Lesions of LAD Bifurcation Treated by Rotablation
- Operator: Paul Hsien-Li Kao, MD
Case Presentation
An 80-year-old female has complained of dyspnea on exertion (NYHA Fc II) for 2 months ago. She received PCI at the proximal to mid LAD and diagonal artery 11 years ago. Her coronary risk factors were hypertension and hyperlipidemia. Echocardiography showed reduced EF (42%) with akinesia of mid anteroseptum and apical septum. Thallium SPECT showed reversible large-sized severely decreased perfusion defect in LAD territory.
Baseline Coronary Angiogram
  1. The left coronary angiogram showed mild stenosis of the distal LCx and very tight in-stent restenosis of the proximal to mid LAD and diagonal artery ( Movie 1, Movie 2, Movie 3, Movie 4).
  2. The right coronary angiogram showed mild stenosis at the proximal to mid RCA (Post-adenosine FFR 0.92) ( Movie 5).
Procedure
An 8 Fr long sheath was inserted through the right femoral artery and the left coronary artery was engaged with an 8 Fr XB 3.5 guiding catheter. The wire, 0.014-inch Sion wire, was inserted into the LAD and another wire, 0.014-in Sion Blue wire, was inserted into the diagonal branch. We checked IVUS at both LAD and DI, which showed severe ring-shaped calcified plaque on the previous stents, after applying compliant balloon dilation up to 6 atm (1.2mm) at the LAD ( Movie 6, Movie 7, Figure 1). We decided to perform rotablation for the heavily calcified in-stent restenotic lesion. A 0.014 inch Rotawire was inserted at the LAD and stepwise rotablation was done with 1.75 mm burr ( Movie 8). Then, a 0.014 inch Rotawire was inserted to diagonal branch and stepwise rotablation was done with 1.75 mm burr ( Movie 9) as well. After rotablation, the diameter of the LAD and diagonal branch ostium became bigger. We applied non-compliant balloon dilation up to 24 atm (3.2 mm) at both the proximal to mid LAD and diagonal branch several times to obtain enough space for subsequent drug-eluting balloons (Figure 2, Figure 3, Movie 10). We applied drug-eluting balloon dilation up to 10 atm (3.24 mm) at both the proximal to mid LAD and diagonal branch by kissing balloon (Figure 4). The final angiogram showed good results ( Movie 11, Movie 12).

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