Precision Percutaneous Coronary Intervention of a Complex Lesion

Author(s): Nooraldaem Yousif, Fawaz Bardooli, Tajammul Hussain, Husam A. Noor*

Journal Name: Reviews on Recent Clinical Trials

Volume 16 , Issue 2 , 2021

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Graphical Abstract:


Background: Balloon dilation and atherectomy have several limitations in the treatment of heavily calcific coronary lesions.

Introduction: Intravascular lithotripsy (IVL) is a state-of-the-art system that modifies severe calcific coronary plaques efficiently. In this paper, we report our experience with IVL in the context of a calcific in-stent chronic total occlusion.

Case Summary: A 75-year-old gentleman whose status was post percutaneous coronary intervention, with the deployment of two overlapping bare-metal stents in the mid-left anterior descending artery (LAD) 20 years ago, was admitted to our cardiac center for the elective intervention of in-stent chronic total occlusion (CTO) of LAD, which was performed using an antegrade wire escalation (AWE) technique. After recanalization of the CTO body, optical coherence tomography pullback confirmed a very high calcium score. Balloon dilatation attempts failed, so we proceeded with shockwave lithotripsy with successful full expansion of the 3.5-mm IVL balloon followed by a straightforward stent delivery. The procedure was complicated by distal wire perforation, which was handled in a timely manner with coil embolization. The patient’s postoperative course was uneventful.

Conclusion: This case illustrates the feasibility and effectiveness of IVL that powerfully cracks coronary calcium while minimizing vessel wall trauma in the context of heavily calcific in-stent CTO. In our case, coronary perforation occurred in a small-caliber side branch, which was identified in a timely manner before hemodynamic compromise and treated successfully straight away with coil embolization.

Keywords: Optical coherence tomography, in-stent restenosis, chronic total occlusion, shockwave lithotripsy, percutaneous coronary intervention, case report.

Kobayashi Y, Okura H, Kume T, et al. Impact of target lesion coronary calcification on stent expansion. Circ J 2014; 78(9): 2209-14.[] [PMID: 25017740]
Sakakura K, Ako J, Wada H, et al. Comparison of frequency of complications with on-label versus off-label use of rotational atherectomy. Am J Cardiol 2012; 110(4): 498-501.[] [PMID: 22579342]
Lee T, Shlofmitz RA, Song L, et al. The effectiveness of excimer laser angioplasty to treat coronary in-stent restenosis with peri-stent calcium as assessed by optical coherence tomography. EuroIntervention 2019; 15(3): e279-88.[] [PMID: 29769164]
Brinton TJ, Ali ZA, Hill JM, et al. Feasibility of shockwave coronary intravascular lithotripsy for the treatment of calcified coronary stenoses. Circulation 2019; 139(6): 834-6.[] [PMID: 30715944]
Ali ZA, Brinton TJ, Hill JM, et al. Optical coherence tomography characterization of coronary lithoplasty for treatment of calcified lesions: first description. JACC Cardiovasc Imaging 2017; 10(8): 897-906.[] [PMID: 28797412]
Ali ZA, Nef H, Escaned J, et al. Safety and Effectiveness of Coronary Intravascular Lithotripsy for Treatment of Severely Calcified Coronary Stenoses: The Disrupt CAD II Study. Circ Cardiovasc Interv 2019; 12(10)e008434[] [PMID: 31553205]
Lindsay AC, Paulo M, Kadriye K, et al. Predictors of stent strut malapposition in calcified vessels using frequency-domain optical coherence tomography. J Invasive Cardiol 2013; 25(9): 429-34.[PMID: 23995714]
Fujino A, Mintz GS, Lee T, et al. Predictors of calcium fracture derived from balloon angioplasty and its effect on stent expansion assessed by optical coherence tomography. JACC Cardiovasc Interv 2018; 11(10): 1015-7.[] [PMID: 29798768]
Rakowski T, Węgiel M, Siudak Z, et al. Prevalence and Predictors of Coronary Artery Perforation During Percutaneous Coronary Interventions (from the ORPKI National Registry in Poland). Am J Cardiol 2019; 124(8): 1186-9.[] [PMID: 31439282]

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Article Details

Year: 2021
Published on: 09 October, 2020
Page: [220 - 224]
Pages: 5
DOI: 10.2174/1574887115666201009123721
Price: $65

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