An 81-year-old male with a history of hypertension and hyperlipidemia underwent a left heart catheterization procedure following a positive stress test and was referred to Zaheed Tai, DO, for a possible intervention. The left heart cath, performed via a right radial approach due to operator preference, showed intermediate disease in the circumflex and obtuse marginal-1 (OM-1) arteries, a high-grade stenosis of the proximal to mid right coronary artery, and a 70-80% calcified stenosis of the proximal to mid left anterior descending (LAD) artery. Upon review of the diagnostic angiograms, a decision was made to perform a fractional flow reserve (FFR) test of the circumflex and OM-1 vessels, along with revascularization of the LAD by means of rotational atherectomy.
The 5 French (Fr) GlideSheath (Terumo, Somerset, New Jersey) used for the right radial diagnostic procedure was exchanged for a 6 Fr GlideSheath for the interventional procedure. A Q3.5 guide catheter (Boston Scientific, Natick, Mass.) was advanced and engaged into the left coronary artery system. For anticoagulation, 2,500 units of heparin were administered and a PrimeWire (Volcano Corp., Rancho Cordova, Calif.) was inserted and zeroed according to company protocol. After advancing the wire into the circumflex distal to the lesion, a baseline measurement was read at 1.0. Adenosine was started as an IV infusion at a rate of 140mcg/kg/min and was continued for a duration of two minutes, at the end of which the mean gradient measured 0.95. As the infusion continued, the PrimeWire was pulled back and manipulated into the OM-1 distal to the lesion. The mean gradient in this vessel was measured at 0.92 and the infusion was discontinued. It was decided that neither of these vessels qualified for angioplasty based on the data reported in the FAME trial.1 The PrimeWire was removed and an angiogram was performed, showing no dissection or perforation of either artery.
In preparation for the angioplasty of the LAD, both a bivalirudin bolus (Angiomax, The Medicines Co., Parsippany, New Jersey) and drip were administered for anticoagulation. A RotoWire Floppy (Boston Scientific) was inserted and advanced to the proximal portion of the vessel, but was unable to be manipulated to the distal. A 1.25 Sprinter over-the-wire (OTW) balloon (Medtronic, Minneapolis, Minn.) was inserted to assist with wire manipulation and the RotoWire was exchanged for a .014 Kinetix Plus wire (Boston Scientific). This, too, was difficult to manipulate into the distal vessel and was exchanged through the balloon for a .014 Runthrough wire (Terumo) that finally advanced. The balloon was advanced to the distal portion of the vessel over the Runthrough wire and once again wire exchanged occurred, allowing the RotoWire to be placed in the distal vessel and the balloon to be removed for the atherectomy procedure. A 1.5mm RotoBurr (Boston Scientific) was inserted to the proximal LAD and two passes were made from the proximal to middle portion of the vessel using 155,000 rpm for 15 seconds on each pass. A polishing run was then performed at the same settings and the RotoBurr was removed under the Dynaglide mode. No hemodynamic changes were noted during the procedure and post angiography showed less calcification of the vessel with no evidence of dissection.
After the rotational atherectomy was completed, the OTW balloon was reinserted and the RotoWire was exchanged for a .014 Wiggle wire (Abbott Vascular, Redwood City, Calif.) after which the balloon was again removed. The .014 Runthrough wire was also reinserted for extra support as a buddy wire. A 3.0 x 15 mm AngioSculpt scoring balloon (AngioScore, Inc., Fremont, Calif.) was inserted to the mid portion of the vessel and inflated to 4 atmospheres. The Runthrough wire was removed and two overlapping Endeavor stents (Medtronic) were then placed, covering the entire stenosed area. A 3.0 x 30 mm stent was deployed at 9 atm in the mid LAD and a 3.0 x 18 mm was deployed at 12 atm in the proximal to mid LAD. Upon completion of the stent deployment, the Runthrough wire was again inserted as a buddy wire and an intravascular ultrasound (IVUS) was performed with the iCross catheter and iLab imaging system (Boston Scientific). Both stents were shown to be appropriately sized and well opposed throughout. Although the IVUS procedure showed proper apposition, postdilation of the area of stent overlap was determined to be appropriate and was performed by inflating a 3.25 x 20 mm Quantum Apex non-compliant balloon (Boston Scientific) to 20 atm.
Post interventional procedure, the balloon and both wires were removed. Nitroglycerin (150 mcg) was administered intra-arterially by the physician and post procedure angiography was performed. The LAD was shown to have TIMI-3 flow and no residual stenosis in the stented area. There was also no evidence of dissection, perforation, or distal embolization. The patient went home the next day.
This case demonstrates the ability to perform complex procedures via the radial approach. Dr. Zaheed Tai notes, “Adequate vessel prep is important to facilitate stent delivery and achieve a good angiographic outcome. This is more important via a radial approach where guide support may not be comparable to a femoral approach, particularily since the majority of transradial PCI is performed with a 6 Fr system. Given the heavily calcified nature of the vessel, our options were to aggressively dilate with progressively larger balloons and risk dissection (possible back to the ostium) or debulk to minimize the risk of dissection and then stent. The AngioSculpt balloon provided further plaque modification at the lesion, and allowed us to stay in a 6 Fr system and achieve an excellent angiographic outcome without an additional burr, possibly requiring an upsizing of the system or using multiple balloons to deliver the stent.”
Orlando Marrero can be contacted with at Orlando.Marrero@WinterHavenHospital.org.
- Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009 Jan 15;360(3):213-224.