Twenty-four hours later, he was brought back to the cardiac catheterization laboratory where he was intubated, and the IABP was removed. Arterial and venous cannulae where then inserted via the femoral approach for cardiopulmonary bypass support (i.e., ECMO). Next, an 8-french JL4 guide catheter was then used to engage the left main coronary artery. A 0.014″ guidewire was navigated through the LM lesion and into the first OM of the LCX artery. Using a 2.0″ over the wire balloon, the Fielder wire was exchanged for a 0.09 Roto extra-support wire (Fig. 9.4).

After removal of the over-the-wire balloon, rotational atherectomy was performed with a 1.25 mm burr from the LM and into the proximal LCX and into the first OM. Rotational atherectomy was performed at 150,000 rpm, and multiple passes are made until the burr moved freely without resistance or decelerations. The 1.25 mm burr was removed, and using an over-the-wire balloon, the Roto wire was redirected into the ongoing LCX. A 1.5 mm burr was advanced, and the procedural steps were repeated (Figs. 9.5 and 9.6). Follow-up angiography at this point demonstrated a type C NHLBI (also referred to as Ellis type I vessel perforation – contained) vessel dissection (Fig. 9.5, Video 8.1). As the patient remained hemodynamically stable, we elected not to give up wire position in the LCX because of the dissection. Using an over-the-wire balloon, the LCX Roto wire was exchanged out for a standard 0.014″ wire. We next directed a hydrophilic 0.014″ wire through the LAD lesion and into the distal vessel. Using an over-the-wire balloon, we exchanged out the LAD wire for a roto 0.009″ wire. With the additional wire in the LCX, it becomes critical not to begin rotational atherectomy until the burr is beyond the LCX wire (Fig. 9.7). Rotational atherectomy was performed using a 1.5 mm followed by a 1.75 mm burr. After adequate atherectomy, the burr was removed, and using an over the wire balloon, the Roto wire was exchanged out for a standard 0.014″ guidewire.