Get big solutions whenever you need them
Author: Dr. Perez de Prado Hospital – Universitario de León Spain.
Currently, it is quite common to face cases in which the operator must push the boundaries of coronary devices. Different solutions have been proposed to overcome large discrepancies in reference diameter when coronary bifur- cations are treated: from 4 different designs of the same stent to fit all the potential diameters of a coronary artery to a “universal” stent that could be used in most cases.
In any case, most of the available DESs look for a wide range of overexpansion to accommodate the most challenging bifurcations, which is especially important in the case of distal left main coronary disease, or in aneurysmatic arteries.
A 78 year old male was admitted to hospital after suffering a NSTEMI, with peak US troponin-T of 90 ng/ ml. The patient underwent a coronary angiography that showed 2-vessel disease, with severe coronary cal- cification.
The LAD showed a severe proximal stenosis in a segment with a 90o bend and extreme calcification. The proximal reference diameter was 6.00mm, distal reference diameter seems to be 4.00mm and the first diagonal branch showed severe lesion of a subdivision. The LCx arose from a common ostium with RCA, with an abnormal course but without significant lesions. The RCA was chronically occluded in the proximal segment. Hypoperfusion of the distal vessel was visualized from heterocoronary collaterals.
The case was presented to the Heart Team Session and surgery was contraindicated because of very high surgical risk. The case was accepted for PCI with rotational atherectomy in the LAD (and eventual PCI of the diagonal branch).
The initial strategy included a radial approach with Slender 7-in-6 sheath, 7F guiding catheter EBU4 and an initial attempt to cross the LAD lesion (Figure 1) with Rotawire, 1.75mm burr. The first step of the intended procedure failed: right radial pulse was absent after previous diagnostic coronariography. The left radial and ulnar arteries were extremely calcified (Figure 2) so we moved to right femoral approach with a 7F sheath. Note the patchy calcification of the artery (Figure 3). Moreover, the Rotawire could not be advanced through the proximal lesion. Sion Blue ES also failed to cross of the lesion; afterwards Sion Black wire was used, also unsuccessfully.
We succeded with some support using a standard microcatheter. After exchanging of wires, we decided to downgrade the Rotablator burr to 1.25mm, but the burr became sta- lled at the curve proximal to the lesion. Careful withdrawal of the whole system (guidewire, burr and guiding catheter) allowed us to advance the burr from a more proximal location. Five attempts to cross the lesion were unsuccessful (Figure 4). Finally, the burr managed to cross the lesion, allowing the passage of Sion Blue ES to the diagonal branch.
The lesion at the subdivision of the diagonal and the LAD lesion were dilated with a 2.00mm SC balloon. IVUS run was performed, showing a high degree of severe calcification as well as severe persisting stenosis (Figure 5). The proximal LAD lesion was dilated with a 5.00mm NC balloon and a 4.00x24mm Angiolite was implanted (Figure 6) to avoid distal overexpansion, although IVUS showed > 6.00mm distal diame- ter. Angiolite performed excellently showing neither deformation nor shortening on IVUS.
IVUS exam showed significant underexpansion of the stent (Figure 7). In view of that, a 6.00mm NC balloon was used in the proximal part of the stent (Figure 8) with significant lumen gain (Figure 9). Signi- ficant underexpansion was evident at the distal part of the stent (Figure 10), but NC 6.00mm was also applied with evident lumen gain of this segment (Figure 11) by end the procedure.
The final result showed an excellent angiographic result (Figure 12).
When there are large discrepancies in the diameters of coronary arteries, one of the most important features to consider for a DES is its overexpansion capacity in order to accommodate to the most challenging lesions. In this complex case, Angiolite DES has shown its excellent performance with a high overexpansion capacity. Angiolite has been correctly apposed to the vessel, and IVUS assessment has confirmed that Angiolite did not suffer deformation or shortening, adjusting perfectly to the entire lesion.
Figure 1. LAD with a severe proximal stenosis in a segment with a 90o bend
Figure 3. Patchy calcification of the artery
Figure 4. Unsuccessful attempts to cross the lesion
Figure 5. IVUS showing a high degree of severe calcification
Figure 6. Angiolite 4.00×24 successfully implanted
Figure 7. IVUS exam showing significant proximal underexpansion of the stent
Figure 8. 6.00mm NC balloon used in the proximal part of the stent
Figure 9. Significant lumen gain observed in the proximal part by angiography
Figure 10. Significant underexpansion was evident at the distal part of the stent