64 year old gentleman who is a non smoker and has a significant past medical history of hypertension and hyperlipidemia. He presented to our clinic with symptoms of angina for the last few weeks. Physical examination was unremarkable.

CT coronary angiogram was performed showing calcium score of 3247 and triple vessel disease. Echocardiogram showed normal ejection fraction and no significant valvular function.

Coronary angiogram showed middle left main 30%, middle left anterior descending artery 80%, distal left anterior descending artery 80%, middle right coronary artery 80%, right posterior descending artery 90% and right posterolateral artery 80%. We proceeded with angioplasty of the LAD and for staged procedure of the right coronary artery. The mid LAD was stented with a 2.5 x 23 mm drug eluting stent and the distal LAD treated with 2 x 30 mm drug coated balloon.

We performed angioplasty of the RCA via the right radial approach with a 6 French sheath. 6 Fr AL 1 guide catheter to RCA and a Runthrough NS wire used to cross the lesion. Dragonfly OCT catheter pullback shows calcified nodule with a MLA of 1.64 mm2. Exchanged to Viper stiff wire with Mizuki microcatheter. We performed 6 runs of orbital artherectomy at low speed with Diamondback Orbital device and then 6 runs at high speed. Repeat OCT shows improvement in MLA to 2.81 mm2. We then predilated with w Wolverine 4 x 15 mm cutting balloon and a Sapphire 4.5 x 15 mm NC balloon. Repeat OCT now shows improved MLA to 6.41 mm2. A Synergy Megatron 5 x 20 mm DES stent was deployed across the lesion and this was post dilated with a Sapphire 5 x 12 mm NC balloon. Repeat OCT run shows good area expansion with a distal MSA of 15.56 mm2 and proximal MSA of 20.33 mm2. Final angiogram good results.

Calcified nodules are associated with poor stent expansion and elliptical shaped stents post stenting. Orbital atherectomy maybe a good treatment tool for such lesions as nodule debulking prior to stent deployment improves stent expansion.