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-027
When Encountering Double Trouble, Primary Orbital Atherectomy Delivers a Niche Solution: Safe and Effective Use of Upfront Orbital Atherectomy in Heavily Calcified Chronic Total Occlusion
By Zhong Shiun Lee, Adriyawan Widya Nugraha, Shahul Hamid K A Ahmadsah, Muhamad Ali SK Abdul Kader
Presenter
Zhong Shiun Lee
Authors
Zhong Shiun Lee1, Adriyawan Widya Nugraha2, Shahul Hamid K A Ahmadsah3, Muhamad Ali SK Abdul Kader4
Affiliation
Penang General Hospital, Malaysia1, Dr. Iskak Tulungagung Hospital, Indonesia2, Hospital Pulau Pinang, Malaysia3, Sultan Idris Shah Serdang Hospital, Malaysia4,
View Study Report
TCTAP C-027
CORONARY - Adjunctive Procedures (Thrombectomy, Atherectomy, Special Balloons)
When Encountering Double Trouble, Primary Orbital Atherectomy Delivers a Niche Solution: Safe and Effective Use of Upfront Orbital Atherectomy in Heavily Calcified Chronic Total Occlusion
Zhong Shiun Lee1, Adriyawan Widya Nugraha2, Shahul Hamid K A Ahmadsah3, Muhamad Ali SK Abdul Kader4
Penang General Hospital, Malaysia1, Dr. Iskak Tulungagung Hospital, Indonesia2, Hospital Pulau Pinang, Malaysia3, Sultan Idris Shah Serdang Hospital, Malaysia4,
Clinical Information
Patient initials or Identifier Number
LSC
Relevant Clinical History and Physical Exam
49 years old gentleman with underlying type 2 diabetes mellitus, hypertension and dyslipidaemia presented to our centre with history of progressive reduced effort tolerance. He was diagnosed with ischemic HFrEF with LV clot which resolved with 3 months of Warfarin. Coronary angiogram revealed 2 vessels disease with heavily calcified LAD. After discussion with patient regarding complex PCI, he was readmitted for staged PCI to LAD.
Relevant Test Results Prior to Catheterization
Echocardiogram in June 2020 revealed impaired LVEF (30-35%) with global hypokinesia and apical LV clot, which resolved after anticoagulation with Warfarin for 3 months. Cardiac magnetic resonance imaging in August 2020 revealed findings consistent with ischaemic cardiomyopathy with all segments being viable and resolution of LV clot.
Relevant Catheterization Findings
Right dominant system. 95% stenosis with heavy calcification of proximal to mid LAD. 70% stenosis Ramus intermedius. 50-60% stenosis of mid and distal RCA, 80% stenosis RPDA.
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2A.mov 2B.mov 5A.movInterventional Management
Procedural Step
Our initial strategy was for PCI to heavily calcified LAD with plaque modification with atherectomy via right femoral approach. However, repeat angiogram revealed progression of LAD disease to a CTO with J-CTO score 2 with Rentrop 2 collateral from RCA.
We then decided for antegrade approach of CTO with subsequent calcified plaque modification with atherectomy. Procedure was done via bifemoral arterial access with 6Fr sheaths. Left coronary system was engaged with XBLAD 3.5 guiding catheter and RCA was engaged with JR4 diagnostic catheter. Antegrade wire escalation with Teleport microcatheter support was done, starting with Fielder XT-R, and CTO was crossed with ASAHI Gaia second wire, which was exchanged with ViperWire. Diamondback 360 orbital atherectomy system was done for 4 runs upfront at low speed without prior balloon predilatation. Subsequently done balloon dilatation with Sapphire II 2.0 x 10mm from mid to ostial LAD. Mid LAD was stented with COMBO PLUS 2.75 x 28mm, while ostial to mid LAD was stented with COMBO PLUS 3.0 x 28mm. Final result was good with TIMI 3 flow. Patient was discharged well without complications and had improvement of clinical symptoms.
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We then decided for antegrade approach of CTO with subsequent calcified plaque modification with atherectomy. Procedure was done via bifemoral arterial access with 6Fr sheaths. Left coronary system was engaged with XBLAD 3.5 guiding catheter and RCA was engaged with JR4 diagnostic catheter. Antegrade wire escalation with Teleport microcatheter support was done, starting with Fielder XT-R, and CTO was crossed with ASAHI Gaia second wire, which was exchanged with ViperWire. Diamondback 360 orbital atherectomy system was done for 4 runs upfront at low speed without prior balloon predilatation. Subsequently done balloon dilatation with Sapphire II 2.0 x 10mm from mid to ostial LAD. Mid LAD was stented with COMBO PLUS 2.75 x 28mm, while ostial to mid LAD was stented with COMBO PLUS 3.0 x 28mm. Final result was good with TIMI 3 flow. Patient was discharged well without complications and had improvement of clinical symptoms.
9A.mov 10A.mov 49A.movCase Summary
This is a gentleman with high ischemic profile who underwent successful PCI to heavily calcified CTO LAD with antegrade wire escalation with microcatheter support, and modification of calcified plaque with primary/ upfront orbital atherectomy. There is limited data on use of atherectomy in PCI of heavily calcified CTO lesions, and the use of primary/ upfront atherectomy in this select group of patients is even rarer. This case illustrates a safe and effective outcome of PCI of calcified CTO lesion treated with primary orbital atherectomy.