1
Summary
Heavily calcified lesions are encountered with increasing frequency during percutaneous coronary interventions (PCI). Although stent implantation is feasible in most cases, severely calcified coronary lesions pose a specific challenge as balloon dilatation and stent placement can be difficult or even impossible, often leads to suboptimal stent expansion, which in turn is a major cause of stent restenosis and thrombosis.
Rotational atherectomy (RA) is an effective and indispensable device for modifying fibrocalcific coronary lesions and facilitating stent placement. Rotablator burr entrapment occurring during rotational atherectomy is a rare but serious complication that can lead to coronary occlusion and require emergency cardiac surgery.
We report a case of a rotational atherectomy in a lesion with stent under expansion due to heavily calcified plaque in the context of acute coronary syndrome and acute stent thrombosis. Complicated with an entrapped rotablator burr and successful removed using the subintimal tracking and reentry (Mini-STAR) technique.
2
Case description
A 69 years old woman was admitted to the emergency room with a diagnosis of acute anteroseptal myocardial infarction.
The patient’s medical history included diabetes, chronic angina, she came to the hospital due to a chest pain, in his evaluation in the emergency room, an ECG show ST segment elevation of the anteroseptal location, because there was no availability of hemodynamic room, pharmacological reperfusion was performed with tecteneplase, which was successful, a coronary angiogram 6 h later showed significant narrowing with calcification in the middle of the left anterior descending coronary artery (LAD) and performed PCI for the lesion, with Judkins 6 FR (Medtronic, INC., MN), A whisper Es guidewire was crossed through the narrowed portion, despite inflation of an TREK 2.5 × 15 mm balloon (Abbott, CA, USA) up to 16 atm, the lesion could not be dilated, with a residual waist on the balloon due to the calcification.
However the operators decided to implant two stents, Synergy 2.5 × 24 mm up to 16 atm (Boston Scientific Corporation, MA) and Synergy 3 × 28 mm, with a residual waist, then performed a inflation with a TREK 3 × 12 mm balloon but without achieving adequate stent expansion, but with TIMI 3 Flow ( Fig. 1 AB,C,D,E).
The patient was translate to the unit coronary, stable without angina, twelve hours later the patient presented sudden dead with ventricular fibrillation, ECGs show anteroseptal ST elevation that indicates acute thrombosis of the stent. Therefore, we decided to perform rotational atherectomy in an attempt to ablate partially the stent and underlying calcium to allow subsequent stent expansion, because in our hospital we do not have coronary laser therapy.
A guiding catheter (7 Fr, Voda) was inserted into the left coronary artery through the left femoral artery, a PT Graphix intermediate 0.014″ (Boston Scientific Corporation, MA) guidewire was advanced across de subexpansion stent and A Finecross microcatheter (Terumo Corporation) was used to exchange the wire with RotaWire wire (Boston Scientific Corporation, MA). Rotablation was performed using a Rota Link Plus 1.25-mm burr (Boston Scientific Corporation), with 180,000 rpm with a cocktail infusion of verapamil, nitroglycerin, and heparin mixed in pressurized saline, without achieving adequate stent expansion (NC Quantum 2.5 × 8 mm), additional rotational atherectomy with a 1.5 mm burr was performed, Suddenly, the burr was entrapped in the stent and subsequent pullback maneuvers were not successful. Simultaneously, the blood flow in the LAD decreased to TIMI 0. We decided performed a Ping-Pong technique by right radial approach with a BAT (Balloon assisted tracking) 7FR Voda Guiding catheter, because a small radial artery in a women and recent closure of the right femoral puncture site with an Angioseal. This made it possible to introduce a second coronary wire (Pilot 150; Abbott Vascular) through the same guiding catheter however, no were able to cross the lesion. So we decide to use a technique described for chronic total occlusions by Dr. Galassi (Mini-STAR) as a modification of the technique described as bailout by Dr. Tanaka and Dr. Saito for the removal of trapped burr (Modified STAR). We placed a Finecross microcatheter at the burr and with a Progress 40 guidewire advance through the subintima, the wire assumes the J-shape configuration, that penetrates the occlusion through a sub-intimal plane, across the stuck rotablator burr an reentering in the distal true lumen, balloon dilatation with mini Trek 1.2 × 8 mm between the subintima and Under expanded stent was performed, which finally enabled us to pull the rotablator system into the guiding catheter. A Workhorse guidewire was advanced across the true lumen to distal of LAD, and despite incomplete rotablation of the distal part of the stent, it successfully expanded using a non-compliant balloon (NC Quantum 3.0 × 12 mm).
Finally, a Synergy 3.0 × 16 mm was successfully implanted follow by NC Quantum 3.5 × 15 with a fully expanded of the stent. ( Fig. 2 G, H, I, J, K, L).
2
Case description
A 69 years old woman was admitted to the emergency room with a diagnosis of acute anteroseptal myocardial infarction.
The patient’s medical history included diabetes, chronic angina, she came to the hospital due to a chest pain, in his evaluation in the emergency room, an ECG show ST segment elevation of the anteroseptal location, because there was no availability of hemodynamic room, pharmacological reperfusion was performed with tecteneplase, which was successful, a coronary angiogram 6 h later showed significant narrowing with calcification in the middle of the left anterior descending coronary artery (LAD) and performed PCI for the lesion, with Judkins 6 FR (Medtronic, INC., MN), A whisper Es guidewire was crossed through the narrowed portion, despite inflation of an TREK 2.5 × 15 mm balloon (Abbott, CA, USA) up to 16 atm, the lesion could not be dilated, with a residual waist on the balloon due to the calcification.
However the operators decided to implant two stents, Synergy 2.5 × 24 mm up to 16 atm (Boston Scientific Corporation, MA) and Synergy 3 × 28 mm, with a residual waist, then performed a inflation with a TREK 3 × 12 mm balloon but without achieving adequate stent expansion, but with TIMI 3 Flow ( Fig. 1 AB,C,D,E).
