Clinical Images

Adjunctive Rotational Atherectomy and Intravascular Lithotripsy for Heavily Calcified Left Main Disease Via Radial Access

Fernando Macaya, MD;  Julian Yeoh, MBBS, FRACP;  Jonathan Hill, MA, FRCP;  Rafal Dworakowski, PhD, FRCP

Fernando Macaya, MD;  Julian Yeoh, MBBS, FRACP;  Jonathan Hill, MA, FRCP;  Rafal Dworakowski, PhD, FRCP

J INVASIVE CARDIOL 2020;32(4):E99.

Key words: cardiac imaging, lithotripsy, left main, radial access, rotablation

A 77-year-old man with diabetes, atrial fibrillation, and chronic lymphocytic leukemia with cryoglobulinemia presented with stable angina. Coronary angiography demonstrated severe distal left main (LM) disease with heavy concentric calcification extending into the left anterior descending (LAD) and circumflex (LCX) arteries (Figures 1A and 1B; Video 1). The right coronary artery was unobstructed and left ventricular systolic function was moderately impaired. He was deemed unsuitable for cardiac surgery due to the increased risk of infection and thrombosis during extracorporeal circulation. Percutaneous coronary intervention (PCI) was planned with radial access to reduce bleeding risk. 

A 7 Fr sheath and an extra-backup guide catheter were used. A medium-support hydrophilic wire crossed the LCX lesion. Based on the tactile roughness and heavy load of calcium on the angiogram, rotational atherectomy (RA) was utilized with 1.5 and 1.75 mm burrs in both the LCX and LAD to debulk plaque and facilitate deliverability in subsequent steps. Intravascular ultrasound (IVUS) obtained following RA demonstrated circumferential distribution of calcification without fragmentation (Figures 1C, 1E, 1H). Further preparation with intravascular lithotripsy was then applied using a 3.5 mm balloon to deliver 40 shocks in each limb. IVUS subsequently showed calcium fractures (Figures 1F and 1I). Culotte stenting was then performed with 3.5 x 28 mm and 3.5 x 33 mm everolimus-eluting stents in the LCX and LAD, respectively. Final steps included postdilation with a 6.0 mm NC balloon in the LM, 4.0 mm NC balloons in both limbs, and simultaneous kissing-balloon inflation with 3.5 x 20 mm NC balloons. A final dilation of the LM was performed using the 6.0 mm balloon. The angiographic and IVUS result was satisfactory (Figures 1D, 1G, 1J). Three-month follow-up with angiography and optical coherence tomography of the LAD (Video 2) confirmed pleasing results.

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From King’s College Hospital, London, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted September 10, 2019.

Address for correspondence: Fernando Macaya, Denmark Hill, Brixton, London, SE5 9RS. Email: