A 75-year-old man had come to our hospital complaining of chest pain from last night. He had underwent chemotherapy with paclitaxel and gemcitabine against unresectable pancreatic cancer for a year in our hospital.His clinical course of cancer had been good but he suffered from interstitial pneumonia induced by side effects of chemotherapy, so his respiratory function had tended to worsen.However, his prognosis had been still expected to be at least over a year at then.

Electrocardiography showed ST elevation remarkably in V1 to V5 inductions.Laboratory data demonstrated elevation of cardiac enzymes, CPK was 1212 U/L, CPK-MB was 155.5 ng/mL, and high-sensitive Troponin I was 7979.1 pg/mL. His renal function was normal, but chronic anemia (Hb 9.9g/dL) was found due to chemotherapy.Echocardiography showed 40% of ejection fraction and severe hypokinesis of anterior wall of left ventricular.We diagnosed STEMI and performed emergent coronary angiography (CAG).

CAG showed that there was 99% stenosis at seg7 of LAD, 75% stenosis at ramus intermediate, focal 99% stenosis at seg2 of RCA, and flow of LAD was TIMI grade 1.That why we judged LAD was culprit lesion and decided to revascularization by PCI.Angiography suggested that there was diffuse severe calcified plaque at the culprit lesion of LAD. Therefore, we inserted IABP from left femoral artery because we might performed debulking by atherectomy device even if in this severe condition of STEMI.

We selected 7Fr Mach1 Q3,5 guiding catheter (Boston scientific, USA).We could cross the wire to distal LAD, but not deliver the Ryurei semi-compliant balloon 1.5×10mm (Terumo,Japan) or Anteowl IVUS (Terumo, Japan) due to severe calcification. For thatreason, we had no choice but to performed rotablator (Boston scientific, USA).We selected 1.5mm burr and debulked the lesion of seg7. After successful debulking, we administered nicorandil 2mg and nitroprusside 60μg with microcatheter in LAD.IVUS revealed diffuse severe calcified lesion in throughout seg7 of LAD. We performed OCT with Dragonfly OpStarcatheter (Abott Medical, USA) to value thickness of calcified plaque.OCT revealed thickness of calcified plaque was over 1000 μm. We considered selecting large size burr and continue debulking, but it was high possibility to occur slow flow or no reflow phenomenon. In addition, even if we continued debulking with big size burr, it might be a possibility of getting under expansion because the calcification was extremely thick.Therefore, we delivered 2.5 mmsemi-compliant Shockwave Lithoplasty balloon (Shockwave Medical, USA) to the lesion of seg7, and performed in eight cycles of 10 seconds. After lithotripsy, OCT showed several calcium cracks in the lesion.We finally put the Resolute Onyx DES 2.5×38mm, 3.5×34mm DES (Medtronic, USA) in the lesion, and OCT revealed enough expansion of implanted stents.We finally gained TIMI 3 flow and enough expansion of the lesion successfully.

We finally could successful revascularization in a single procedure by combination therapy with rotablator and lithotripsy. Rotablator has advantage of passage performance in calcified lesion, but it might occur slow flow or no reflow phenomenon. On the other hand, lithotripsy has low risk of those complications, but has disadvantage of poor deliver-ability of lithoplasty balloon. Therefore, combination with rotablator and lithotripsy could compensate for shortcoming each other devices, and it makes possible to more effective approach for severe calcified lesions. Especially, it would be one of an effective option or alternative strategy in severe situation like this case.