Rotational Atherectomy: If You Do Not Do It Before, You Can Do It After Stenting

ABSTRACT: We report the treatment of three severely underexpanded freshly deployed stent layers in the proximal left anterior descending artery, despite 24 atm inflation pressure, due to heavily calcified plaque. Rotational atherectomy, using a high rpm and a stepped burr strategy, successfully ablated the stent layers and the protruding calcified plaque. Subsequently, balloon angioplasty resulted in stent expansion and the treated segment was scaffolded with another stent, finally obtaining an excellent angiographic result. The patient’s evolution was satisfactory. This case shows that rotational atherectomy can be a useful tool in a compromising situation, such as severely underexpanded implanted stents.

J INVASIVE CARDIOL: 2014;26(9):E122-E123

KEY WORDS: post-stenting rotational atherectomy, calcification

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Percutaneous coronary intervention (PCI) in calcified lesions is a challenge for interventional cardiologists. Devices for plaque modification, such as rotational atherectomy (RA), are often needed to achieve appropriate expansion and apposition of stents.¹ After successful vessel dilatation with RA, drug-eluting stent (DES) implantation usually takes place.^2-5 Although its usefulness is clear, RA is inevitably associated with major adverse cardiac events (death, non Q-wave myocardial infarction, or target vessel revascularization) in a subset of patients, especially diabetics and those with de novo lesions.⁶

Stents implanted in rigid and calcified lesions don’t always achieve adequate expansion despite high-pressure inflations. High-speed RA has been previously used in this scenario, producing stent and protruding calcified plaque ablation that facilitates posterior balloon dilatation.^7-9 We present the case of a patient with a calcified lesion in which three layers of implanted stents were underexpanded in whom RA was performed afterward, achieving lesion expansion.

Case Report. A 75-year-old patient with a past medical history of an abdominal aorta aneurysm treated with an endoprosthesis was admitted due to inferior wall ST-segment elevation myocardial infarction. Primary PCI with implantation of two DESs in an occluded right coronary artery was performed. A severely calcified obstructive long lesion was observed in the mid-proximal left anterior descending (LAD) artery (Figure 1A), so PCI to the LAD was scheduled 3 days later. The patient had a preserved left ventricular ejection fraction.

Initially, 16 atm dilatation of a 2.0 x 20 mm compliant balloon in the mid LAD was successful, but 18 atm dilatation of the same balloon in the proximal LAD did not totally dilate a focal very calcified portion. Following this, a DES (Resolute 2.5 x 26 mm; Medtronic) was implanted in the mid LAD with a good angiographic result. Another DES (Resolute 2.5 x 26 mm) was implanted in the proximal LAD, but there was no adequate expansion of the focal segment previously described. Inflations of a 2.5 x 8 mm non-compliant (NC) balloon at 20 atm and 24 atm did not achieve sufficient postdilatation. With the intention that short, higher diameter stents, with elevated radial force, could successfully dilate the lesion, two DESs (Nobori 3 x 8 mm [Terumo Corporation] and Xience 3 x 8 mm [Abbott Vascular]) were implanted, but despite this, underexpansion was evident (Figure 1B). At this point, PCI with RA (Rotablator; Boston Scientific) was performed.

The JL4 guiding catheter was exchanged for the higher support XBU4. Due to difficulties in advancing the Rotablator Extra Support guidewire (Boston Scientific) through the lesion, a Whisper MS (Abbott Vascular) was advanced and exchanged through a Finecross catheter (Terumo) for the Extra Support guidewire. A 1.25 mm burr was advanced through the lesion, with difficulties, at almost 200,000 rpm, but after this, a 2.5 mm NC balloon couldn’t dilate the stented lesion. Next, a 1.5 mm burr at 165,000 rpm was passed (Figure 1C); at this point, a 2.75 mm NC balloon was successfully dilated at 20 atm. Finally, a 3 x 18 mm Xience DES was implanted in the proximal LAD (Figure 1D and 1E). Another DES (Xience 3 x 15 mm) was placed in the ostial LAD to cover an area of ostial dissection. The LCX had preserved flow. The patient was discharged without complications.

Discussion. It is usually difficult to know beforehand whether a calcified lesion will need a “debulking” method, such as RA, for its dilation. Therefore, the decision to use RA is usually made after balloon dilatation is unsuccessful, before DES implantation. This is the first case to our knowledge in which RA has been successfully used for ablation of three layers of freshly implanted stents. Although passage of the Rotablator through a freshly implanted underexpanded stent is considered a probable risk factor for a rare but life-threatening complication (stuck rotablator), a low burr to artery ratio may help prevent this.¹⁰ The use of high-speed ablation is also probably useful for a good result.

References

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8. Kobayashi Y, Teirstein PS, Linnemeier TJ, et al. Rotational atherectomy (stentablation) in a lesion with stent underexpansion due to heavily calcified plaque. Catheter Cardiovasc Interv. 2001;52(2):208-211.
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10. Sulimov DS, Abdel-Wahab M, Toelg R, et al. Stuck Rotablator: the nightmare of rotational atherectomy. Eurointervention. 2013;9(2):251-258.

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From the Department of Interventional Cardiology, University Hospital La Paz, Madrid, Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted December 16, 2013, and accepted January 8, 2014.

Address for correspondence: Joel Hernandez: MD, University Hospital La Paz, Paseo de la Castellana, 261, Madrid Spain 28046. Email: jjoel_7@hotmail.com