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Patient initials or identifier number
Relevant clinical history and physical exam
A 73-year-old Chinese man with no known medical illness, presented with angina of 2-hour duration. His blood pressure was 118/74 mmHg and heart rate 97 beats per minute. ECG showed ST segment elevation over leads V2–V5, I, aVL and aVR. He has acute extensive anterolateral ST elevation myocardial infarction Killip I. The patient received intravenous tenecteplase bolus dose. However, ECG post-60 minutes showed failed reperfusion and rescue percutaneous coronary intervention was done.
Relevant test results prior to catheterization
Hemoglobin level showed 11.8 g/dl.
Creatinine level was 101 micromol/liter.
Urea was 3.6 mmol/liter.
Both total and LDL cholesterols were 4.7 and 3.2 mmol/liter.
INR level 1.0 and APTT was 27.1 seconds.
Relevant catheterization findings
Coronary angiogram was performed via right radial artery approach using 6F sheath and Optitorque Tig 5F catheter. Left coronary artery showed left main stem (LMS) total occlusion (TIMI 0 flow) and heavily calcified vessels. Right coronary artery showed 50% stenosis of mid and distal segments supplying collaterals to left anterior descending and left circumflex arteries.
The XBLAD 6F engaged to the left coronary ostium. Left anterior descending (LAD) and left circumflex (LCX) arteries crossed with Runthrough NS wires (Terumo, Tokyo). A lesion involving left main stem (LMS) and LAD was sequentially predilated using 2.5 x 10 mm Yangtze semi-compliant balloon (APR Medtech, Oxon) at 8–16 atm, Non-Compliant Quantum Apex balloon (Boston Scientific, Marlborough) 2.5 x 12 mm was inflated at 12–17 atm, and scoring balloon Scoreflex (Orbus Neich, Hong Kong) 2.0 x 10 mm up to 22 atm.
Significant calcific stenosis persisted and this was modified using Rotablator (Boston Scientific, Marlborough) with burr size 1.5 mm starting from 160000 rpm applied from LMS to mid-LAD.
The lesion subsequently was predilated using Tazuna semi-compliant balloon (Terumo, Tokyo) 2.0 x 10 at 20 atm and NC Quantum Apex balloon 2.5 x 12 mm at 26 atm. Orsiro sirolimus-eluting stent (Biotronik, Switzerland) 2.5 x 30 mm at 14 atm and Orsiro stent 3.0 x 22 mm at 12 atm were deployed from LMS to mid-LAD. Post dilation was completed by using Yangtze non-compliant balloon 2.75 x 15 mm at 14–26 atm.
The final result showed TIMI 3 flow for both LAD and LCX. There was no residual waisting observed on both stents angiographically. Stent edge dissection was not seen. The patient was discharged well after 6 days of hospitalization. Dual antiplatelet therapy advised for at least 1 year or more.
This case illustrates heavily calcified plaque burden complicated by plaque rupture leading to acute coronary total occlusion. Rotational atherectomy is useful to modify plaque characteristics in a heavily calcified vessel and be considered if lesion preparation is suboptimal despite using cutting balloons and non-compliant balloons. Rotational atherectomy may be performed in emergencies such as ST elevation myocardial infarction with failed fibrinolytic therapy and may be carried out safely using radial artery approach.