J INVASIVE CARDIOL 2020;32(7):E194-E195.
Key words: angiography, cardiac imaging, optical coherence tomography
A 72-year-old male had acute inferior-wall myocardial infarction, for which he was subjected to primary angioplasty at another institute. Coronary angiography revealed a thrombotic 95% occlusion of the proximal right coronary artery (RCA) (Figure 1A). Percutaneous coronary intervention (PCI) was attempted but failed, as the coronary guidewire could not cross the lesion. There was TIMI 0 flow across the RCA at the end of the abandoned procedure (Figure 1B; Video 1). He was referred to our institute for a repeat PCI.
Repeat coronary angiography revealed 95% eccentric calcified stenosis of the mid RCA with TIMI 3 flow (Figure 1C). The lesion was crossed with a BMW coronary guidewire (Abbott Vascular); however, various-sized angioplasty balloon catheters could cross the lesion. The guidewire was exchanged with a floppy-tip Rotawire (Boston Scientific) and the lesion was ablated with a 1.5 mm Rotaburr (Boston Scientific) (Figure 1D). It was further dilated with a 2.5 mm balloon, followed by a 3 mm non-compliant balloon. Optical coherence tomography (OCT) imaging (St. Jude Medical, Abbott Vascular) revealed calcific, superficial plaque throughout the RCA with a 270°-360° arc of calcification. There were multiple protruding calcific nodules at the point of maximum stenosis (Figure 2; Video 2). Two overlapping 4 x 23 mm and 3.5 x 33 mm Xience Prime stents (Abbott Vascular) were deployed from ostial to mid RCA, and TIMI 3 flow was achieved (Figure 1E; Video 3). Repeat OCT showed well-apposed and expanded stent across the RCA (Video 4). The patient was asymptomatic at 6-month follow-up.
The acute coronary syndrome is usually due to plaque rupture or erosion. A calcified nodule is an infrequent pathological substrate in such patients. The index case had calcified nodules with added thrombosis as the cause of acute myocardial infarction. It also demonstrated the technical challenges of intervening an eccentric, severely calcified, balloon-uncrossable coronary lesion.
From the Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
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 November 6, 2019.
Address for correspondence: Prof (Dr) Rajesh Vijayvergiya, MD, DM, FSCAI, FISES, FACC, Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh–160 012, India. Email: firstname.lastname@example.org