JACC

Lots of interesting abstracts and cases were submitted for TCTAP 2021 Virtual. Below are accepted ones after thoroughly reviewed by our official reviewers. Don’t miss the opportunity to explore your knowledge and interact with authors as well as virtual participants by sharing your opinion!

TCTAP C-016 . Presentation

Presenter

Siti Dalila Adnan

Authors

Siti Dalila Adnan1, Nor Halwani Habizal1, Kamaraj Selvaraj1, Asri Ranga2, Abd Kahar Abd Ghapar2

Affiliation

Serdang Hospital, Malaysia1, Hospital Serdang, Malaysia2,
View Study Report
TCTAP C-016
CORONARY - Adjunctive Procedures (Thrombectomy, Atherectomy, Special Balloons)

A Case of Successful Rotational Atherectomy in a Dissected and Ectatic Right Coronary Artery

Siti Dalila Adnan1, Nor Halwani Habizal1, Kamaraj Selvaraj1, Asri Ranga2, Abd Kahar Abd Ghapar2

Serdang Hospital, Malaysia1, Hospital Serdang, Malaysia2,

Clinical Information

Patient initials or Identifier Number

SD01046128

Relevant Clinical History and Physical Exam

A 76-year-old male, ex-smoker with a past medical history of Ischemic Heart Disease. Cardiovascular risk factors including Type II Diabetic Mellitus, Hypertension, Coronary Artery Disease, Cerebro Vascular Accident (CVA)He presented with sudden onset of crushing chest pain associated with exertional dyspnoea.Clinical examination.:Blood pressure 123/65 mmHg Heart rate of 88/minCardiovascular and respiratory system were unremarkable.No other abnormalities in other systemic physical examination.

Relevant Test Results Prior to Catheterization

Renal Profile: Urea 4.8, Na 142, K 3.8, Creatinine 114FBC: Hb 15.1, WCC 8.5, Platelet 271Echocardiogram: demonstrated a left ventricular function of 65% with no regional wall motion hypokinesiaElectrocardiogram (ECG) showed regular sinus rhythm, with ST segment depression at inferior leads

Relevant Catheterization Findings

LM: no significant stenosisLAD: Ostial LAD 50% stenosis, mid to distal LAD moderate diseaseLCX: Ectatic vessel, proximal to mid LCX moderate 60-70%, distal LCX and OM bifurcation lesion, CTO at OM1RCA: Ectatic and Calcified vessel with multiple tandem lesion from distal to proximal RCA causing  70-90% stenosis.Presence of thin line dissection at proximal RCA, TIMI 3 flow, which was further confirmed with IVUS images. Noted dissection of calcified plaque extending into tunica media, no flap.


rca1.avi

Interventional Management

Procedural Step

Radial approach with 6Fr JR3.5 guiding catheterTransvenous temporary pacemaker inserted via right femoral vein, anticipating transient bradycardia during RCA intervention Run-through floppy with fine cross micro catheter wired into RCA.Proceed with rota 1.7 burr, 160K RPM
IVUS
Segment MLA (mm2) Lumen diameter (mm) Vessel diameter (mm) Plaque Burden (%)
Distal RCA 14.64 4.24 / 4.40 6.61 / 6.92 59
Mid RCA (lesion) 10.32 3.26 / 3.92 5.7 / 5.74 59

Predilated with :- dRCA-ostialRCA Sapphire NC 3.5x15mm at 16-20 ATM- dRCA-ostialRCA Scoreflex 3.5x15mm at 14 ATM
Stented with :- distal-midRCA Onyx 4.5x30mm at 12 ATM- midRCA-pRCA Onyx 4.5x26mm at 12 ATM- proxRCA-ostialRCA Onyx 4.5x18mm at 12-16 ATM
Postdilated with :- distalRCA-ostialRCA with Sapphire NC 4.5mmx15mm at 16-20 ATM, Ostial flare done 20ATM
IVUS post
Segment MLA (mm2) Lumen diameter (mm) Vessel diameter (mm) Plaque Burden (%)
Distal RCA 16.23 4.46/4.63 5.89/6.41 44
Mid RCA (lesion) 15.19 4.28/4.51 5.41/5.78 38

Well opposed stent, no dissection


postpci.avi

Case Summary

Presence of coronary vessel dissection had been considered as a strong contraindication to rotational atherectomy. This mainly due to concern of subintimal delivery of the atherectomy burr and resultant in coronary perforation. 

Learning points from this case:
1. Choice of debulking agent: rotational vs orbital atherectomy  
2. IVUS guided PCI was used to confirm the dissection part, degree of calcification and guide the selection of stent size
3. Successful PCI to Ectatic RCA with delivery of THREE 4.5 mm stent size from distal to ostial 
4. Careful delivery of rotablator 1.75 mm burr at 160,000 rpm was used, avoiding any tendency for the burr to lurch forward preventing propagation of dissection.

Leave Comments

TCTAP 2021 Virtual Apr 12, 2021
Very impressive! Thanks for sharing this study report.