Mrs. Lee

The patient was a 76 year-old female who underwent hemodialysis for over 10 years. She presented with chest pain in progression for weeks. We tried medical control first but chest pain was still on and off. Blood pressure dropped during and light headedness was found during hemodialysis. Under the impression of unstable angina, we arranged coronary angiography for her.

ECG showed ST depression over V1-4 and lead II, III, aVF.CXR showed cardiomegaly and tortuous and calcified aorta.The cardiac echo showed preserved LVEF but hypokinesis was noted over lateral wall. The thallium scan showed >10 % reversible ischemia over anterior, septal and inferior wall. Scar formation was found over lateral wall. 

CAG showed severe calcification and tight stenosis over middle LAD. The calcification was close to myocardial side and the two angle at middle LAD looked like "Z" shape. The 2nd curve looked so acute (nearly 90 degree from lateral view). LCX was also heavily calcified and was total occluded.  Some collaterals from the diagnoal branch fed the distal LCX. As for RCA, the middle of RCA was also severe stenosis and heavily calcified. 
002.AVI
003.AVI
005.AVI

Initially, i spent a short time for LCX total occlusion. I tried loose tissue tracking with Sion black-->XTR--> Gaia 1st but could not cross the lesion. The territory of distal LCX was not large, so i focused on LAD and RCA lesions.For LAD, I started with 1.25 mm burr with rota-floppy wire. To avoid burr stuck in the middle of "Z", i set the platform more proximally and ablate the proximal angle first and then moved forward to the second angle. The 2nd curve looked so acute especially from the lateral view. I tried to operate the burr slowly like cruising motion but could not pass the 2nd angle easily. After several runs of ablation, i shifted to 1.5mm burr because the tail of 1.25mm burr is longer than 1.5mm burr. Sometimes 1.5mm can work better than 1.25mm burr. If 1.5mm burr also failed, i would consider halfway rota. Fortunately, the 1.5mm passed the lesion. Then, i performed balloon angioplasty with 2.5mm semi-compliant balloon, and then 2.75 mm cutting balloon. The lesion was well dilated, so i deployed two DES with NC 3.0-3.5mm post-dilation.
Finally, i treated RCA, with 1.5mm burr (IVUS no pass), then after checking IVUS, I upgraded to 2.0mm burr. After ablation, i performed balloon angioplasty with 3.5mm balloon and deployed one DES with NC 4mm post-dilation.
1.25mm bur could not pass.AVI
1.5mm burr pass the lesion.AVI
After stenting and NC plasty.AVI

To ablate calcification effectively and safely is always challenging especially for cases with acute curve. When a burr cannot penetrate the lesion, downsizing of the burr is generally recommended. However, we experienced a case with LAD double curve lesion which could not be easily crossed with 1.25mm burr but could be crossed with 1.5mm burr. The underlying mechanism could be the uncoated part of 1.25mm burr was longer than 1.5mm burr.