Lots of interesting abstracts and cases were submitted for TCTAP 2022. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!
TCTAP C-019
A Case Using Halfway Rotational Atherectomy
By Hei Yu Zoe Chu
Presenter
Hei Yu Zoe Chu
Authors
Hei Yu Zoe Chu1
Affiliation
Tuen Mun Hospital, Hong Kong, China1,
View Study Report
TCTAP C-019
CORONARY - Adjunctive Procedures (Thrombectomy, Atherectomy, Special Balloons)
A Case Using Halfway Rotational Atherectomy
Hei Yu Zoe Chu1
Tuen Mun Hospital, Hong Kong, China1,
Clinical Information
Patient initials or Identifier Number
Ms. Ng W. Y.
Relevant Clinical History and Physical Exam
Ms. Ng is a 75 year old lady, with a history of insulin dependent type 2 diabetes, hypertension, end-stage renal failure on peritoneal dialysis, and paroxysmal atrial fibrillation.She has a history of recurrent ACS, with first PCI done in 2000 with stenting to dRCA and dLCx. Another episode of NSTEMI in 2017 resulted in further stenting to RCA CTO and pLCx. 4 years later she experienced recurrence of angina, for which an elective PCI was arranged.
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RightCoronary75fps_4_1.mp4 RightCoronary75fps_86_1.mp4Relevant Test Results Prior to Catheterization
Her pre-operative echocardiogram shows normal LVEF and no RWMA, valves were unremarkable. Her ECG showed AF, narrow QRS, with no acute ST/ T changes and no pathological Q waves.
Relevant Catheterization Findings
Coronary angiogram showed that all of the RCA stents were patent. The left main was unremarkable. For the LAD, it was heavily calcified from proximal segment onwards, with ostial to proximal D1 and D2 artery 70% stenosis. LCx stent was patent, there was minor disease in distal LCx.
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Procedural Step
We used a 7 Fr EBU 3.5 guide catheter. We attempted to predilate pLAD lesion with a small compliant balloon, but were unable to deliver larger non-compliant balloon through the lesion. So we decided to perform Rotablation with a 1.5 Rotaburr.
We were unable to push Rotaburr beyond an angulated bend. Repeated attempts with Rotablation was complicated with Rotawire kinking in dLAD. We attempted to remove the wire with gentle traction first, but were unsuccessful. We tried to remove it with hard tip microcatheters such as MAMBA and Finecross, but were unable to deliver them to dLAD. As we had some success delivering small compliant balloon to dLAD earlier in the procedure, we tried to remove the Rotawire with the use of a 1.5 over the wire balloon and finally succeeded.
Further predilation to LAD was done with a 0.85/10 compliant balloon and a 2.0/15 non-compliant balloon. This time we were successful in delivering these balloons to more distal part of LAD despite not being able to perform Rotablation through the entire LAD lesion. We then performed intravascular lithotripsy to mLAD using a 2.5 shockwave balloon. We wired D2 with another workhorse wire and performed Mini-crush for LAD/D2 bifurcation. D2 was stented with a 2.0/28 DES, crushed with NC balloon in LAD. LAD stented with 2.5/33 DES. First POT with a 3.0/6 NC balloon done. D2 was rewired with Fielder FC. Kissing with 2.0/15 NC balloon in D2 and 2.5/15 NC balloon in LAD performed. Final POT with 3.0/6 NC balloon done.
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We were unable to push Rotaburr beyond an angulated bend. Repeated attempts with Rotablation was complicated with Rotawire kinking in dLAD. We attempted to remove the wire with gentle traction first, but were unsuccessful. We tried to remove it with hard tip microcatheters such as MAMBA and Finecross, but were unable to deliver them to dLAD. As we had some success delivering small compliant balloon to dLAD earlier in the procedure, we tried to remove the Rotawire with the use of a 1.5 over the wire balloon and finally succeeded.
Further predilation to LAD was done with a 0.85/10 compliant balloon and a 2.0/15 non-compliant balloon. This time we were successful in delivering these balloons to more distal part of LAD despite not being able to perform Rotablation through the entire LAD lesion. We then performed intravascular lithotripsy to mLAD using a 2.5 shockwave balloon. We wired D2 with another workhorse wire and performed Mini-crush for LAD/D2 bifurcation. D2 was stented with a 2.0/28 DES, crushed with NC balloon in LAD. LAD stented with 2.5/33 DES. First POT with a 3.0/6 NC balloon done. D2 was rewired with Fielder FC. Kissing with 2.0/15 NC balloon in D2 and 2.5/15 NC balloon in LAD performed. Final POT with 3.0/6 NC balloon done.
Fluoroscopy_11_1.mp4 Fluoroscopy_17_1.mp4 unnamed_1917_1.mp4Case Summary
We would like to use this case to illustrate the use of halfway rotational atherectomy. In conventional rotational atherectomy, the Burr is advanced to the end of a continuous calcified lesion, followed by balloon dilatation. However, persistence in trying to advance Rotablation beyond acute bends may result in wire kinking (as in our case), coronary perforation and Burr entrapment. In halfway rotational atherectomy, the Burr is advanced but not beyond any acute angle within lesion, and for lesions where the Burr has not touched, balloon dilatation or intravascular lithotripsy is used instead. Delivery of the balloons will be easier after Halfway Rotablation.