J INVASIVE CARDIOL 2020;32(6):E175.
Key words: coronary calcification, intravascular lithotripsy, rotablation, rotational atherectomy, Shockwave
A 66-year-old man with end-stage renal disease was admitted with inferolateral STEMI due to occlusion of a heavily calcified circumflex (CX) artery (Figure 1A; Video 1). Primary angioplasty was performed and flow was restored after dilations with a 1.5 mm balloon. A 2.0 mm balloon was advanced over the lesion only after using a buddy wire and a guide-catheter extension, but could not be expanded adequately. We were unable to advance a 2.5 mm non-compliant balloon despite implementing the above highly supportive maneuvers. The procedure was completed at this stage, with TIMI 3 flow across the CX (Video 2).
Three weeks later, the patient was brought back to the cath lab. A significant >90% residual stenosis was present in the calcified CX (Figure 1B; Video 3). Rotational atherectomy (RA) was performed using a 1.5 mm burr at 180,000 rpm (Figure 1C; Video 4). However, the lesion was undilatable using a 3.0 non-compliant balloon at high pressure. Therefore, we employed intracoronary lithotripsy (Shockwave Medical) for additional modification of the calcified plaque. Using a 3.5 x 12 mm Shockwave balloon, we delivered 3 runs of 10 pulses with excellent expansion of the balloon at low pressure (4-6 atm) (Figure 1D; Video 5). Post-lithotripsy angiogram showed a significant modification of the calcified lesion (Figure 1E; Video 6). We then implanted two 3.5 mm zotarolimus-eluting stents followed by postdilation with a 4.0 mm non-compliant balloon, with excellent angiographic result (Figure 1F; Video 7).
Primary balloon angioplasty is still a reasonable initial option for a STEMI due to an undilatable, heavily calcified stenosis, provided that TIMI 3 flow can be achieved. RA and intracoronary lithotripsy are potentially complementary techniques in specific clinical scenarios. In balloon-uncrossable calcified lesions, RA is the first-line modality to enable operators to advance balloons and stents over the stenosis. If the lesion is undilatable after RA, a hybrid approach with additional intracoronary lithotripsy (rotatripsy) can be an effective approach that further modifies the calcified plaque and enables stent delivery.
From 1the 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece; and 2the Department of Cardiology, Laiko Hospital, Athens, Greece.
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 December 23, 2019.
Address for correspondence: Konstantinos Aznaouridis, MD, PhD, 1st Department of Cardiology, Hippokration Hospital, 114 Vas. Sofias Avenue, 11527 Athens, Greece. Email: email@example.com