SHLV01052616

A 63 year old female presented with a chief complaint of angina CCS grade 3 and dyspnea on exertion. Her comorbidities were controlled hypertension. Her current medications were Aspirin 80 mg OD, Clopidogrel 75 mg OD, Atorvastatin 40 mg OD. She denied family history of coronary artery disease. She looked frail and weighed 45 kg. Her cardiopulmonary examination was normal. Non-contrast CT scan of the thorax showed a hyperdense lesion observed on the projection of the right coronary artery. 

Her 12-lead ECG showed normal sinus rhythm with no Q waves and  no ST segment and T wave deviation. Echocardiography showed normal left ventricular function and no regional wall motion abnormalities.

Angiography showed calcified stenosis to osteal RCA and non-significant lesions to distal RCA and proximal LAD. PCI targeted the osteal RCA lesion, with the remaining lesions to be managed conservatively.

Guiding catheter used JR 3.5/7F. Initially, IVUS (Volcano Therapeutics, USA) did not cross due to severe calcification. Orbital atherectomy used Diamondback® OAS (CSI, USA) with 1 antegrade and 1 retrograde run. Post retrograde run, she was agitated and felt chest discomfort. Angiography showed aortocoronary dissection.   In attempting to exchange wires,  the Viper wire lost engagement.   While re-wiring, she developed unstable bradycardia. Temporary pacemaker was implanted.  Still unstable, echocardiography showed pericardial effusion. Pericardiocentesis evacuated 25 cc of hemorrhagic fluid, stabilizing her. Rewiring was successful. After predilation and stenting with 3.5/15 Orsiro (Biotronik, Germany), dissection persisted with contrast extravasation. Graftmaster 2.8/15 (Abbott Laboratories, USA) cover stent was placed and postdilated with NC Sapphire 3.5/10 (OrbusNeich, Hong Kong). IVUS showed MSA 7.4 mm2.  In the ICU, she became dyspneic. X-ray showed pleural effusion and pleural puncture was performed. She stayed dyspneic, non-contrast chest CT showed hemopneumothorax. WSD drained hemorrhagic fluid. She stabilized and was discharged with DAPT Aspirin 80 mg OD and Ticagrelor 90 mg BD. 3 days later, she suffered GI bleeding, Haemoglobin 9.7 g/dl, BARC 3A likely due to potent antiplatelet. Ticagrelor was switched to Clopidogrel 75 mg OD and her condition improved.

We have presented a patient with a series of orbital atherectomy related complications such as aortocoronary dissection, cardiac tamponade, hemopneumothorax and GI bleeding. These complications are mitigated by adequate anticipation and a systematic approach of management.