JACC

Lots of interesting abstracts and cases were submitted for TCTAP 2021 Virtual. Below are accepted ones after thoroughly reviewed by our official reviewers. Don’t miss the opportunity to explore your knowledge and interact with authors as well as virtual participants by sharing your opinion!

TCTAP C-021 . Presentation

Presenter

Afif Ashari

Authors

Afif Ashari1, Shaiful Azmi Yahaya1, Wan Faizal Bin Wan Rahimi Shah1, Faizal Khan Abdullah1, Faten Aqilah Aris1

Affiliation

National Heart Institute, Malaysia1,
View Study Report
TCTAP C-021
CORONARY - Adjunctive Procedures (Thrombectomy, Atherectomy, Special Balloons)

Rotablation in a Heavily Calcified, Uncrossable Chronic Total Occlusion Lesion

Afif Ashari1, Shaiful Azmi Yahaya1, Wan Faizal Bin Wan Rahimi Shah1, Faizal Khan Abdullah1, Faten Aqilah Aris1

National Heart Institute, Malaysia1,

Clinical Information

Patient initials or Identifier Number

AMBY

Relevant Clinical History and Physical Exam

65 year old with history of old anterior MI and decompensated heart failure, with underlying Hypertension and end stage renal failure on haemodialysis.Coronary angiogram initially showed 2 vessel disease - Chronic total occlusion (CTO) RCA and subtotal lesion in LADEchocardiogram showed poor LV functionAfter optimized heart failure with furosemide and dialysis initially opted for medical therapy Few months later with intradialytic hypotension and agreeable for high risk angioplasty

Relevant Test Results Prior to Catheterization

ECG - normal sinus rhythm with abnormal R wave progression, T wave inversion lateralTroponin T - 504ProBNP - > 35000Transthoracic echocardiogram - Left ventricular ejection fraction 15-20%, RV function normal (TAPSE 1.7cm), and no significant valvular pathologyTechnetium Scan (viability) - small non transmural infarct RCA territory with otherwise viable myocardium

Relevant Catheterization Findings

Initial Coronary angiogram - 2 vessel disease Left main stem - normalLeft anterior descending (LAD) artery - Subtotal occlusion proximalLeft circumflex artery - mild diseaseRight coronary artery (RCA) - CTO (subtotal with trickle flow distally) mid segment, very heavily calcified
left - cranial.avi
left.avi
RCA - lao.avi

Interventional Management

Procedural Step

Angioplasty to RCA (CTO)
Procedure supported with Intraaortic balloon pump via left femoral artery - due to poor LV function
Right femoral approach with SAL 1, 6Fr guiding Fielder XT wire used with microcatheter support (CORSAIR)Crossed lesion up to distal RCA only (unable to advance wire further to the heavily calcified mid RCA area)Also unable to advance microcatheter past the mid RCA lesion due to the tight, calcified lesionAttempted predilation with Ryurei 1.0/5mm, sapphire II NC 2.5/10mm Still unable to past the mid RCA calcification despite attempting 'leopard crawl' technique and support with guide extension catheter
Decided to attempt rotablationRewired through the microcatheter at the mid RCA lesion with Rota floppy wireCrossed the lesion but managed to wire only up to the mid-distal RCA segment (unable to advance wire further)Despite this, decided to attempt rotablation to the heavily calcified mid RCA (with risk of poor support and distal wire only short distance past the lesion). Aware of risk of rotablation system jumping out and causing dissection and damage to the vessel.Managed to crack lesion with rotablator with burr crossing lesion
Subsequently no issues advancing balloon to predilate lesionPredilated the mid segment with semi compliant 2.0mm balloon and non compliant (NC) scoring balloon 2.5mmStented mid RCA with 3.5/30mm stent, and post-dilated with NC 3.5/15mm balloonmild-moderate distal RCA disease accepted.Good final results
cto3.avi
rota 3.avi
final1.avi

Case Summary

In calcified total occlusion lesions, need to always be prepared and consider to use adjuncts like rotablation,for better lesion preparation and stent delivery
It is not only about crossing a CTO lesion, but also to deliver the microcatheter and balloons across the lesion. Therefore it is  important to know the adjuncts and techniques available that can be used when having difficulty to cross devices past tight calcified lesions - tapered microcatheters, penetration microcatheters (example: Tornus), or rotablation
Sometimes there are cases that requires unorthodox risky maneuvers, but operators need to be aware of the potential hazards involved and be prepared to salvage them if they occur

Leave Comments

TCTAP 2021 Virtual Apr 12, 2021
Very impressive! Thanks for sharing this study report.