Author + information
- Mitsunori Mutou1
Patient initials or identifier number
Relevant clinical history and physical exam
A dialysis case of a 61-year-old female admitted to our hospital with chest pain on the effort. She had angina pectoris and hypertension. Previously she received PCI because of unstable angina in March 2013 and implanted Endeavor 3.0/30 to proximal RCA and Integrity 3.5/15 to mid-RCA. Three months later after the first PCI, she received PCI again to proximal RCA in-stent restenosis site and implanted Xience 3.0/15 in Endeavor stent.
Relevant test results prior to catheterization
She determined unstable angina again in January 2016 with chest pain and ECG findings. Therefore, we performed coronary angiography.
Relevant catheterization findings
RCA had some severe stenotic tandem lesions with calcium in proximal RCA repeat ISR, mid-RCA ISR, and distal RCA new lesions. LCA had calcium nodule in distal LMT and severe stenosis with calcium in just proximal LCX. On the other hand, coronary flow from LMT to distal LAD was enough including calcium nodule site at distal LMT.
We determined RCA lesions were the culprit because they seemed to be critical.
The surgeon recommended that this case is not suitable for CABG because an anastomotic point of RCA is too distal so graft perfusion area is small. There would lead to graft occlusion.
However, repeat restenosis rate of PCI at DES overlapping site in dialysis case will be high. Therefore, in this case, we will require CABG eventually. Therefore, we had to expand proximal site of RCA anastomotic site without stent in order to obtain enough perfusion area of a graft. Therefore, at first, we performed PCI to RCA with Rotablator. We start the procedure with a femoral approach and used 8F AL 0.75 SH guiding catheter in order to ablate with a large burr. We started rotational atherectomy with 1.5 mm burr from proximal to distal RCA. Then we step up the burr size to 2.0 mm and ablate to mid-RCA including stent overlapping ISR site. Finally, RCA flow improved and we finished this procedure without stent implantation.
However, four months later, she admitted again with chest pain on effort, and we performed CAG again. RCA had restenosis lesions at the same site, so we performed PCI again with OFDI in order to confirm tissue characterization in restenosis site after ablation. OFDI revealed that thrombus was involved to restenosis after rotational atherectomy in this case, and surface adhesion of calcium shown by IVUS. Therefore, we used DCB after expansion with a noncompliant balloon, and RCA flow improved.
RCA in this dialysis case had multiple lesions with calcium including restenosis of stent overlapping site. Furthermore, this case had LCX just proximal lesion with calcium as well. We considered long-term patency of PCI, in this case, will be not enough. On the other hand, this case was not suitable for CABG as well. Therefore, we expanded RCA without a stent and obtained enough perfusion area of graft in order to leave choice both repeat PCI and CABG. In this procedure, rotational atherectomy with large burr was useful. An imaging device is crucial in order to confirm tissue characterization in restenosis site and decide PCI strategy especially repeat restenosis case.