CASE20240807_006
Cracking the Calcium
By Ting Yuen Beh
Presenter
Ting Yuen Beh
Authors
Ting Yuen Beh1
Affiliation
National Heart Institute, Malaysia1,
View Study Report
CASE20240807_006
Complex PCI - Calcified Lesion
Cracking the Calcium
Ting Yuen Beh1
National Heart Institute, Malaysia1,
Clinical Information
Relevant Clinical History and Physical Exam
70 years old lady with hypertension, chronic kidney disease 3A and coronary artery disease. She had history of PCI to LCx in 2011. She presented with angina associated with diaphoresis. ECG showed ST depression V2-V4 with raised troponin T. She was treated as NSTEMI and referred to us. Clinically, her vital signs were stable. No signs of pulmonary congestion. Heart sounds were normal.
CAG.mpg
CAG RAO Cra.mpg
CAG LAO Cra.mpg
CAG.mpg CAG RAO Cra.mpg CAG LAO Cra.mpgRelevant Test Results Prior to Catheterization
Relevant Catheterization Findings
Coronary angiogram:LMS: normalLAD: severe stenosis at proximal LAD with calcificationLCx: severe stenosis at proximal LCx and moderate ISR mid LCxRCA: severe stenosis at distal RCA
Patient refused CABG and opted for multi-vessel PCI
PCI LCx.mpg
post PCI LCx.mpg
Patient refused CABG and opted for multi-vessel PCI
PCI LCx.mpg post PCI LCx.mpgInterventional Management
Procedural Step
PCI LcxEBU 3.0/6FRunthrough floppy wired to LCx and Sion Blue to LAD,Predilated with Scoreflex 2.5/15mm IVUS showed old stent under-expanded with ISR.Further predilated with Scoreflex 3.5/15mm Drug coated balloon angioplasty with Agent Monorail 3.5/20mm @ 10atmProximal LCx stented with Synergy Monorail 3.5/24mm Post dilated with NC 3.75/15mm (14-20atm)IVUS showed good stent apposition with no stent edge dissection
PCI LADRunthrough floppy wired to diagonalIVUS showed 270 degree calcification Predilated with Scoreflex 2.5/15mm (12-20atm) but waisting noted. Failed to deliver Wolverine 3.5/10mm balloon.Changed to IVL Shockwave 3.5mm (4-6atm) for 40 pulses. Balloon opened fully.Further predilated with NC 3.5/15mm (14atm)Stented with Cre9 Evo 3.5/16mm Post dilated with NC 3.75/15mm (14-18atm)IVUS showed good stent apposition with no stent edge dissection
IVL (3).mpg
stent placement.mpg
final.mpg
PCI LADRunthrough floppy wired to diagonalIVUS showed 270 degree calcification Predilated with Scoreflex 2.5/15mm (12-20atm) but waisting noted. Failed to deliver Wolverine 3.5/10mm balloon.Changed to IVL Shockwave 3.5mm (4-6atm) for 40 pulses. Balloon opened fully.Further predilated with NC 3.5/15mm (14atm)Stented with Cre9 Evo 3.5/16mm Post dilated with NC 3.75/15mm (14-18atm)IVUS showed good stent apposition with no stent edge dissection
IVL (3).mpg stent placement.mpg final.mpgCase Summary
This case illustrates calcified vessel preparation during PCI. Initial scoring balloon was unable to open well due to heavy calcification. Cutting balloon was too bulky to be delivered to the target lesion. Subsequently the lesion was prepared well with intravascular lithotripsy and further predilated with NC balloon. The stent managed to open well with good vessel preparation. IVLis an useful tool and easy to use during calcified vessel preparation. This method can be considered during atherectomy for suitable vessels.