CFM

Our patient is a 70-year-old gentleman with underlying hypertension and peripheral artery disease. He had a history of claudication pain for which he had peripheral stenting to the right superficial femoral artery done previously. He presented this time around with multiple admissions for crescendo angina which were increasing in frequency and intensity.

Electrocardiogram (ECG) was unremarkable with normal sinus rhythm and left ventricular hypertrophy by voltage criteria. The transthoracic echocardiogram showed borderline left ventricular hypertrophy with no regional wall motion abnormalities. The patient had a calcified aortic valve but with no significant aortic valve stenosis.

The coronary angiography revealed a double vessel disease with ostial left main (LM) involvement with heavy calcification and a significant calcified lesion in the proximal left anterior descending (LAD). He also had significant stenosis in the mid-segment of the right coronary artery (RCA). The patient was referred to the cardiothoracic team for coronary artery bypass (CABG) surgery. However, the patient refused CABG surgery and was thus referred back to us for multivessel angioplasty.
MOVIE-0006.wmv
MOVIE-0007.wmv

The left main was engaged with a 7Fr guiding catheter EBU 3.5 via the left femoral approach. A BMW was used to wire the LAD and the tightest mid LAD lesion was predilated with a 2.0 millimetre (mm) compliant balloon. An intravascular ultrasound imaging (IVUS) catheter was then advanced to the mid LAD and a pullback to the ostial LM was done. The IVUS images showed a greater than 270 degrees calcium arc in the LM and also slightly lesser degrees of calcium arc in the proximal and mid segments of the LAD ranging between 90-180 degrees. The LM measured 5.0 mm, the proximal LAD measured 4.0mm and the mid LAD measured 3.0mm.
With this important additional information, we then proceeded to perform rotational atherectomy to the LM-LAD using the Rota Pro with a 1.5mm burr at 180,000 rpm. Post rotational atherectomy, the lesion was then sequentially pre dilated with 2.5 cutting, 3.0 non-compliant and 3.0 cutting balloons.
Two drug-eluting stents were deployed; an Orsiro Mission 3.0 x 30mm in the LAD and an Orsiro 3.5x 35mm in the LM (both stents overlapping). We post dilated the stents sequentially with 3.5, 4.0 and 4.5 NC balloons followed by ostial flaring at high pressures. An IVUS run post stenting was done and it showed good apposition of both stents and minimal stent area (MSA) targets were achieved. There were no distal edge dissections and there was adequate ostial LM coverage.
MOVIE-0027.wmv
MOVIE-0094.wmv
MOVIE-0148.wmv

Left main stenting, especially ostial LM stenting in a setting of double vessel disease and moderate to severe calcification would still benefit from CABG surgery. However, given the background of the patient’s frailty and age, left main stenting is a justifiable and equally viable option. To achieve procedural success, it is important to utilize intravascular imaging to accurately assess the left main vessel size as well as to delineate the calcium severity. Application of both IVUS and rotational atherectomy helped immensely in achieving appropriate lesion preparation as well good final apposition of the stents.