KYG

A 56-year-old male patient who had a history of NSTEMI with underlying hypertension and diabetic chronic kidney disease presented to a district hospital with worsening dyspnea.   Dyspnea persisted despite heart failure management and he was transferred after failing primary percutaneous coronary intervention at RCA chronic total occlusion including in-stent restenosis.   He was hemodynamically stable and showed generalized edema. 

The echocardiogram showed LV systolic dysfunction (EF 33.7%) with akinesis at basal to mid inferior, inferolateral LV wall motion and decreased RV function (TAPSE 15.6mm)
PCI was attempted to the RCA CTO lesion, but the patient seizure with complete AV block during the procedure. After guiding catheter pull back to aorta, vital sign was recovered and procedure was stopped.
24 hours holter showed NSVT and intermittent high degree AV block. So ICD implantation was performed before PCI retry.

Coronary Angiography LM : minimal lesionLAD : pdLAD 30 % stenosis. diffuse, concentric, smooth, TIMI 3LCx : LCx Os 95 % stenosis. discrete, eccentric, smooth, TIMI 3RCA : mRCA 100 % stenosis. CTO lesion, TIMI 0, collateral vessel Grade 1 from LAD septal br
LM-angio.avi
RCA-angio.avi

PCI was done to mdRCA CTO lesion with 100% ISR at dRCA   RCA was engaged with a 8Fr AL1 side hole via the Rt. femoral approach and LM was engaged with a 5 Fr JL4 via the Rt. radial approach.Conquest pro wiring supported by Corsair pro microcatheter to dRCA true lumenAfter passage of guidewire, 1.00*5mm balloon and Tornus catheter was not passed due to severe calcification at mRCA (proximal cap)Conquest pro wiring supported by Finecross microcatheterWire exchange to Rota wire through the Finecross at the mRCA lesion Crossed the lesion but managed to wire only up to proximal of the mRCA CTO lesion, failed to advance wire to dRCA. we decided to rotational atherectomy (RA) to proximal cap.Proceed to perform RA to mRCA with 1.25mm burr, 160K RPM, carefully.Post RA, predilated with 1.00*5mm balloon at mRCA CTO lesion and wiring to dRCA but balloon was not passed at dRCA stent ISR lesion again. Rota rewiring supported by Finecross at dRCA.Proceed to perform re-rotablation at dRCA (in stent) with 1.25mm burr, 160K RPM Post RA, predilated with 2.50*15mm balloon at mdRCA lesion.Two drug-eluting stents and one drug-eluting balloon were deployed: an Osiro Mission Stent 3.50*30mm at mdRCA, an 3.50*40 mm at pmRCA (overlapping) and seQuent please DEB 3.00*30mm at dRCA ISR lesion.Stents post dilated with NC balloon 3.75*12mm and 4.0*15mm, sequentially.After final angiography and IVUS imaging, we confirmed acceptable results.
mRCA.avi

Rotational atherectomy is useful in heavy calcified CTO lesion that was not passed by device.   Even if the wire dose not completely pass through the CTO lesion, RA can be used to break the proximal cap. It is a good option and sufficient for procedure success.