Low speed rotational atherectomy

A case of optical coherence tomography image following by rotational atherectomy

A 73 year-old female was admitted for a diagnostic evaluation of exertional chest pain for 2 weeks. She was being treated with hypertension and diabetes mellitus. Treadmill exercise test revealed horizontal ST segment depression of 2 mm in II, III, aVF and V4-6. Coronary angiography(CAG) showed severe stenosis with heavy calcification of mid right coronary artery(RCA) and diffuse intermediate stenosis of proximal to mid left anterior descending artery(LAD). A 3.5x15mm of drug eluting stent using rotational atherectomy was successfully implanted in mid RCA. One year later, she complained chest pain again though dual antiplatelet therapy was continued. The electrocardiography at rest showed newly developed T wave inversion in V1-3. The cardiac biomarkers were not elevated. CAG revealed a patent stent in mid RCA, but mildly aggravated obstructive lesion with diffuse calcification in proximal to mid LAD. We selected left radial artery using 6 Fr 3.5 extra backup guide catheter. Fractional flow reserve measurement was 0.66. Optical coherence tomography(OCT) revealed diffusely circumferential heavy calcification (Figure 1). A 1.5mm burr was gradually advanced to the lesion. Ablation at 180,000 rpm was attempted several times. Followed OCT showed a small crack and microdissections. We tried to dilate the lesion using a 2.5mm high pressure noncomplaince balloon, but it was not enough to dilate the lesion. We switched back to rotational atherectomy with lower speed of 110,000 rpm. OCT revealed more and larger cracks through the lesion. Following dilation with a 2.5mm non-compliant balloon, we deployed two bioresorbable polymer sirolimus-eluting stents (3.0x30mm, 2.75x40mm). The stents were additionally dilated with a 2.75 mm noncompliance balloon. Finally, OCT showed well expanded stents without any complication.

Figure 1. Circumferential heavily calcified lesion

Figure 2. OCT following rotational atherectomy. Surface minor dissections (white arrow) in circumferential calcification lesion after rotational atherectomy at high speed of 180,000 rpm (Left) Major crack (white arrow) after rotational atherectomy at low speed of 110,000 rpm (right)

Pre- Rotational atherectomy

Rotational atherectomy 180,000 rpm

Rotational atherectomy 110,000 rpm