Author + information
- Prem Nathan Arumuganathan1,
- Kamaraj Selvaraj1,
- Abd Kahar Bin Abd Ghapar1,
- Abdul Muizz Bin Abd Malek1 and
- Abdul Raqib Abd Ghani1
Patient initials or identifier number
Relevant clinical history and physical exam
Our patient is a 48 year-old gentleman with underlying long standing Type 2 Diabetes Mellitus (T2DM), hypertension and End Stage Renal Failure (ESRF) on regular haemodialysis complicated with tertiary hyperparathyroidism. He was planned for a parathyroidectomy but it was deferred pending a cardiac assessment.
Unfortunately, he presented to our center with Non ST Elevation Myocardial Infarction (NSTEMI) after multiple episodes of intradialytic hypotension associated with typical angina pectoris.
Relevant test results prior to catheterization
Electrocardiogram (ECG) showed a left ventricular hypertrophy by voltage criteria.
Echocardiography showed a concentric left ventricular hypertrophy with a reduced ejection fraction of 40% with multiple regions of hypokinesia predominantly in the RCA territory. A subsequent myoview scan showed the RCA territory to be non viable with viable LAD and LCx territories.
Relevant catheterization findings
Coronary angiography revealed a heavily calcified double vessel disease with distal left main stem involvement. He had an 80% distal left main disease and ostial LAD with subtotal occlusion of the mid LAD and calcified distal LAD.
All these lesions were severely calcified. The LCx mildly diseased and the proximal RCA was also heavily calcified with 99% disease with TIMI 2 flow.
The left coronary artery was engaged using a 7Fr EBU catheter through the right femoral approach. A 0.014 inch Fielder XTA wire was used to cross the mid LAD lesion with support from a Fine cross micro catheter.
We exchanged into a 0.014 inch Rota wire and performed high speed rotational atherectomy at three different levels. The three lesions or levels treated with rotational atherectomy were the distal left main, mid LAD and distal LAD using a 1.5 mm burr three times at each level. After rotablation, we exchanged to a 0.014 inch BMW wire and predilated the LAD and distal left main with a Tazuna 2.5 x 15 mm, Accuforce 3.5 x 15 mm and Accuforce 4.0 x 15 mm sequentially. The mid LAD was stented with an Orsiro 2.5 x 26 mm at nominal pressure. We then deployed 3 Stentys stents (3.5-4.5 x 27 mm, 3.5-4.5 x 22 mm and 3.5-4.5 x 22 mm) at higher pressure from the mid LAD to the distal left main. The proximal LAD was then post dilated with a Pantera NC balloon 4.5 x 12 mm at high pressure.
The final angiogram showed that the procedure was successful with TIMI 3 flow.
The patient was monitored in our center for 2 days and was able to tolerate haemodialysis well with no episodes of intradialytic hypotension. The RCA was planned for medical therapy in view of non viability of the RCA territory on myoview scan. He has been scheduled for a review by the endocrine surgery team in view of a possible parathyroidectomy at a later date.
Heavily calcified coronary arteries are common among patients with long standing End Stage Renal Failure (ESRF) complicated with hyperparathyroidism. This patient was mostly dependent on his LAD given that his RCA territory was non viable. His frequent angina with intradialytic hypotensive episodes compounded with a recent NSTEMI placed him in a high risk category. Rotational atherectomy at three levels from left main stem to LAD was essential in achieving a successful intervention for this patient. Piotr Kubler et al in a single center registry showed that rotational atherectomy remains necessary for PCI of calcified lesions with satisfactory success and acceptable long term results.