Manage the Calcium but Don’t Forget the Diagonals

By Tsun Ho Lam, Frankie CC Tam


Thomas TH Lam


Tsun Ho Lam1, Frankie CC Tam1


Queen Mary Hospital, Hong Kong, China1,
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Complex PCI - Calcified Lesion

Manage the Calcium but Don’t Forget the Diagonals

Tsun Ho Lam1, Frankie CC Tam1

Queen Mary Hospital, Hong Kong, China1,

Clinical Information

Relevant Clinical History and Physical Exam

Mr Leung was an 85 years old man who suffered from hypertension on losartan. He was admitted for acute non-ST segment elevation acute coronary syndrome. Physical examination was unremarkable. His vital signs were stable. 

Relevant Test Results Prior to Catheterization

Relevant Catheterization Findings

Coronary angiogram showed calcified triple vessel disease. Left main mild stenosis, Left anterior descending artery (LAD) tandem 90-95 % stenosis from proximal to mid portion. Left circumflex artery was non-dominant with a 70 % stenosis over obtuse marginal branch. Right coronary artery had a focal 70 % stenosis over proximal part a 95% critical stenosis over posterolateral branch.

Interventional Management

Procedural Step

Decided to treat LAD tandem lesion first. 7 Fr XB 3.5 was used as guiding catheter. Intravascular ultrasound (IVUS) catheter cannot pass as the vessel was very calcified. Rotablation atherectomy device with 1.5 burr size used. Total 12 passes at 180000 RPM. For provisional stenting approach to LAD. Second diagonal (D2) was wired. Further modified by scoreflex 2.5 mm. Stented with Drug eluting stent from proximal to mid LAD. Noted jailed D2 wire requiring use of small profile balloon and microcatheter to retrieve it. Post-dilatation with non-compliant balloon. Developed chest pain and ST segment elevation. D2 was rewired and kissing balloon inflation was done to LAD/D2. However persistent chest pain. Review of angiogram showed jailed first diagonal. Unable to enter D1 despite Sion black wire. Escalated to Fielder XTA with Corsair Pro XS, but failed to enter true lumen. Decided for subintimal tracking and reentry (STAR) technique. Able to restore TIMI 3 flow finally. 

Case Summary

Calcified lesions can be difficult to management. Atherectomy device may need to be deployed for better lesion preparation. Protruding calcium may result in entrapment of equipment and wiring difficulties. It is important not to overlook the diagonals and they may result in acute vessel closure and hemodynamic compromise. We should be comfortable in handling complications and be familiar with bail out strategies in case of complications.