Mr OKS

An elderly gentleman, 78 year old with multiple co-morbidity.He had recurrent admission for Acute Coronary Syndrome.He had past medical history of Cerebrovascular Accident (CVA) with right sided hemiparesis, Dyslipidaemia, Sick Sinus Syndrome, Diabetes Mellitus and post Transphenoidal Excision for Pituitary Adenoma.Cardiovascular examination showed a systolic murmur at apical region.No other abnormalities in systemic examination. 

Blood test :Renal Profile : Urea 3.6mmol/L, Na 140 mmol/L , K 4.0 mol/L , Creatinine 83 mol/LFBC : Hb 10.6 g/dL, WCC 7.83 x10^9,  Platelet 206x10⁹Fasting blood sugar : 5.3 mmol/LTotal cholesterol : 5.21mmol/L, LDL : 2.98 mmol/L, Triglyceride : 2.30 mmol/L, HDL : 1.18 mmol/LElectrocardiogram : sinus bradycardiaEchocardiogram : demonstrated a left ventricular function of 50% with hypokinesia at anterior wall

LMS : calcified but smoothLAD : calcified vessel from proximal LAD with 90% stenosisRamus intermedius : 80-90% high grade stenosisLcx : proximal LCX mild disease 40-50% stenosis RCA : proximal to mid RCA 50% stenosis, distal RCA 70-80% stenosis


cranial LAD (Converted).mov
xaudal LCX (Converted).mov
rca (Converted).mov

PCI was performed with transradial approach using 6Fr,  EBU 3.5 guiding catheter which gave a good coaxial support.Asahi Sion Blue wire successfully wired down to LAD.Attempted to pre-dilate the calcified proximal LAD with Ryurei 2.0x15mm, however the balloon was unable to cross the tight lesion.We decided to use smaller balloon i.e Ryurei 1.5x15mm, unfortunately the ballon still cannot cross the tight lesion.Unfortunately , patient had chest pain with significant ST elevation on ECG.According to algorithm, we decided to proceed with high speed rotational atherectomy to the calcified lesion to fasicilitate balloon crossability.Fine cross microcather were unable to cross the calcified lesion, we carefully wire down LAD with rota-wire without Microcatheter support. Fortunately, no dissection noted after succesfully wiring down the rota wire.Rotalink Atherectomy done using 1.5 rota burr at 180 rpm for 3 runs , then proceed with polishing for 3 more runs.Further predilatation were performed with Kaneka Raiden 3.0x15mm at high pressure.After adequate lesion preparation, we stented mid LAD with Cre8 Evo 3.0x40mm at 9 atm and proximal LAD with Cre8 Evo 3.5x26mm at 9 atm , unfortunately noted dissection  at proximal edge of stent, therefore we decided to extent the stent coverage till ostial LAD with one more stent , Cre8 Evo 3.5x26mm at 9 ATMPost dilatation done with Accuforce NC ballon 3.5x15mm at high pressure.The final result showed good TIMI III flow, patient were stable.


Pre 1.0.mov
rota1 (Converted).mov
final.mov

Balloon uncrossable and undilatable lesions are frequently encountered in calcified vessel.In our case, after unsuccessful trial of predilatation with small  semi compliance balloon i.e 1.5 and 2.0 mm balloon respectively, and unsuccessful delivery of fine cross microcatheter, we immediately upgraded to second line algorithm i.e by using high speed rotational atherectomy.Learning point:1. Need a quick decision  for calcium modification by using rotational atherectomy because patient developed chest pain with significant ST elevation on cardiac monitoring2. Techniques for uncrossing and undilatable lesion are interchangeable and can be use depending on clinical situation and operator experience.