Rotational Atherectomy Via the Transradial Approach: A Case Report

Indications

A 78-year-old gentleman presented with previous history of post percutaneous coronary intervention of the circumflex artery in 2000 at another center. He reported angina chest discomfort. The patient had a positive stress test with an elevated transient ischemic dilation (TID) score and wall motion abnormalities. Given his risk factors and symptoms, he was referred for left heart catheterization.  

Procedure 

The right radial artery was prepped and draped in a sterile fashion, and accessed with a 6 French Glidesheath (Terumo). A 6 French Judkins Left (JL) 3.5 catheter was used to engage the left system, and a Judkins Right (JR) 4 catheter to engage the right coronary system and perform ventriculography. 

Angiographic findings

Left main:  The left main is calcified, patent, and bifurcates into the left anterior descending coronary artery (LAD) and circumflex artery.  

Left circumflex: The circumflex artery is a moderate-size vessel. There is a high obtuse marginal (OM) 1 small-caliber vessel. OM 2 is a larger-caliber vessel with a patent stent. The atrioventricular (AV) groove is patent.  

Left anterior descending:  The LAD has a proximal diffuse 30% narrowing. The mid portion LAD after the diagonal has a long 80% stenosis with a focal 95%-calcified area. The lesion is approximately 30mm. The remaining mid and distal LAD is patent.

Right coronary artery: The right coronary artery is patent. It is a dominant vessel without any angiographic obstructions.

The left ventricular ejection fraction is approximately 55%, with no transvalvular gradient.

Intervention

Given the patient’s angiographic findings, we chose to intervene on the LAD. We began with a 6 French EBU 3.5 guide catheter (Medtronic) and administered bivalirudin. A .014” Runthrough wire (Terumo) and an over-the-wire balloon were inserted.

There was difficulty in crossing the mid lesion because of heavy calcification. We exchanged for a Rotawire Floppy (Boston Scientific). Using a 1.5 mm burr, two passes were made for a total of 30 seconds, with a polishing run in the mid LAD. The Rotawire was left in place and a Runthrough wire advanced again distally. We tried to advance a 2.5 x 40 mm over-the-wire peripheral AngioSculpt scoring balloon (AngioScore) over the Rotawire to predilate the entire length of the lesion, but the wire did not have enough body through the balloon. After switching out for a long Runthrough wire, the balloon easily advanced into position.

The AngioSculpt was predilated accordingly, for the entire length of the lesion. Intravascular ultrasound (IVUS) was performed to confirm stent sizing. A 3.0 x 30 mm Resolute drug-eluting stent (Medtronic) was advanced. The long Runthrough wire was used as a buddy wire, then removed. The stent was deployed and overlapped proximately with a 3.5 x 15 mm Promus drug-eluting stent (Boston Scientific). We post dilated with 3.25 and 3.5 Quantum balloons (Cook Medical). Final angiography revealed TIMI-3 flow without dissection, perforation, or embolization. IVUS was performed, and demonstrated adequate stent size and apposition, with an excellent angiographic result. The patient tolerated the procedure well. The guide was removed and a TR Band (Terumo) was placed over the radial artery.

Discussion

There are multiple risk factors for coronary calcification: age, diabetes, hypertension and renal insufficiency. Calcified vessels frequently dissect with traditional balloon angioplasty and failure to adequately predilate may lead to stent under expansion, thereby increasing the risk for restenosis or even stent thrombosis. Plaque modification, with devices such as rotational atherectomy, laser atherectomy, cutting balloons and scoring balloons potentially may reduce the incidence of dissection beyond the intended area of treatment. The coronary AngioSculpt is currently available in a maximum length of 20 mm. Given the diffuse nature of the LAD, we chose to dilate with a peripheral AngioSculpt after rotational atherectomy, instead of upsizing the burr for further debulking. Rather than perform multiple inflations with a small sculpting balloon, a peripheral AngioSculpt was used to further “prep” the vessel.

The peripheral AngioSculpt has the same crossing profile as the small coronary dilation catheter, but allows you to treat a larger area with one inflation. This balloon is only available in the OTW version. This is a potential limitation with a short wire. In this case, we already had a long wire Rotawire in place, and easily exchanged for a long Runthrough wire and advanced the AngioSculpt after placement of an additional buddy wire for support.

As a result of the radial approach, guide support may not be as adequate as seen with a femoral approach and the balloon may not deliver easily. Adequate debulking with rotational atherectomy facilitated balloon delivery and further plaque modification (within a 6 Fr system). The stents were easily advanced and there was no angiographic “waste” in the stented segment. 

Orlando Marrero can be contacted at orlm8597@yahoo.com. Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com.