Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
This 58-year-old man with type An aortic dissection with a true lumen, s/p aortic valve resuspension, total arch replacement with 26-8-8-10 four branch graft and TEVAR and HTN suffered from exertional dyspnea and chest tightness for months.
Relevant test results prior to catheterization
Treadmill exercise test: Positive.
2D echocardiography: LVEF 51%, with anterior-septal hypokinesia to akinesia r/o LAD or RCA territory.
ECG Normal sinus rhythm, left axis deviation, left ventricular hypertrophy with repolarization abnormality.
Relevant catheterization findings
Coronary Angiography: - Dominant(R't)
LM - Atherosclerosis
LAD - Calcification, proximal 90% stenosis and middle functional CTO
LCX - Proximal CTO with bridging collateral
RCA - Ectaxia with atherosclerosis
Ramus - Atherosclerosis
Collateral - From RCA to LAD
The LCA engaged with 6Fr EBU 3.5 GC. The LAD was passed with Wizard 78 GW under Pro great MC assist. The calcified lesion failed to pass with Mini-Trek 1.2/6 mm and Sapphire 1.0/5 mm BC. The proximal lesion pre-dilated with sprinter 2.5/15 and then NC Euphora 2.5/8 mm BC 18 bars in order to deep engaging with Guidelinar catheter. Nevertheless, the BC still couldn't be passed. Then Rotablation 1.25 bur to the lesion done.The lesion couldn't be opened by NC Quantum 2.5/8 mm, 2.75/12 mm 28 bars andCutting balloon 2.0/10 mm. The NC balloon rupture was noted. Then the GCchanged to 7Fr EBU 3.75. Rotablation with 2.0 bur was done. After adequate bulking, the lesion opened. Finally, the LAD from ostium to distal portion was stented with Promus Premier 2.5/32 mm, Promus element 2.5/38 mm and PromusPremier 3.0/28 mm. Post-dilation with NC Quantum 2.5/8 mm BC 12-20 bar and 3.0/15 mm 20-22 bars was done. Final TIMI-3 flow with RS<10% was achieved.
The presence of severe calcification in vessels may prevent the full balloon dilatation of a lesion. Rotablator atherectomy is a useful and invaluable tool to deal with such complex lesion in order to optimal stent expansion and apposition for successful treatment.