a case that rotablator was unusable,bacause a lesion was ... okumura.pdfa case that rotablator was...

A case that Rotablator was unusable,bacause a lesion was very calcified and extremely

excentric,we were able to succeed to treat somehow by trans radial intervention

Tokyo Bay Medical Center Hiroshi Okumura

Case 70y’s female

She was nonsmoker,and treated for hypertension,hyperlipidemia and diabetes mellitus. She came to be aware of chest oppression by fast walking from a month ago. She was introduced to our hospital from a clinic because exercise tolerance test was positive.

Severe calcificated and extremely excentric lesion was at middle RCA,and received collateral source from LAD.

The lesion was tortious and severely calcificated.

病歴 6月にハイキングの最中に胸痛を自覚。その後も早歩きなどで胸痛を自覚することあり、当科紹介受診。 <冠動脈CT検査> 3枝とも高度石灰化のため評価困難。 狭心症の疑いで、冠動脈造影検査(ステント留置術)を施行。

Zoom up the lesion！

病歴 6月にハイキングの最中に胸痛を自覚。その後も早歩きなどで胸痛を自覚することあり、当科紹介受診。 <冠動脈CT検査> 3枝とも高度石灰化のため評価困難。 狭心症の疑いで、冠動脈造影検査(ステント留置術)を施行。

By TRI,using 5French Guiding catheter,soft wire crossed the lesion ,supporting microcatheter.

1.0mm balloon could cross the lesion,but 1.5mm balloon could not,and 1.0mm balloon could not cross again.

Size up to 6French system,1.0mm balloon could cross the lesion but it ruptured,and new 1.0mm balloon also ruptured .

And still 1.5mm balloon could not cross the lesion...

What we should do next？

Rotablator bring safety performance this extremely excentric calcified lesion？？

Firstly,we used Tornus catheter for lesion modification safely. And 1.5mm,2.0mm balloon crossed the lesion.

IVUS showed the lesion still remained extreamly excentric and calcified.Scoring balloon could not cross well.

Then secondary,we use dummy wire and dilated the lesion with 2.5mm high pressure balloon,the vessel was dilated enough.

Dummy wire technique

Dummy wire cut calcification by balloon

pressure

Dummy wire

IVUS showed a break at excentric calcification plaque, we could implant drug eluting stent safely,

and coronary blood flowed perfectly.

IVUS showed wire dissection at severe calcification plaque.

Final view1

Final view2

Summary

We experienced angina patient with severe calcified,and extremely excentric lesion. Rotablator was unusable,beacause of high risk coronary perforation. Using 1.0mm balloon manytimes(①), Tornus catheter(②),and dummy wire technique(③),we finally could implant DES perfectly by tansradial intervention. Tornus catheter is useful for the lesion that balloon cannot pass,and dummy wire technique is useful to cut severe calcified plaque.

Conclusion

The lesion was severe calcified and excentric ,so in that situation stent implantation was high risk for coronary perforation. Dummy wire technique is very useful and safely produce vessel dilatation with smaller balloon. Therefore, finally we could implant drug eluting stent safely,and coronary blood flow improved perfectly.

Thank you for attension!!