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  3. Case 15: Rotational Atherectomy and DES of CTO RCA BMS ISR

Case 15: Rotational Atherectomy and DES of CTO RCA BMS ISR

Case Presentation

  • A 55-year-old woman presented with angina chest pain and dyspnea on exertion.
  • A stress MPI revealed moderate antero-septal, and inferior ischemia with mild inferior infarct.
  • Medical History: Hypertension, Hyperlipidemia, ESRD on HD
  • Medications: ASA 81mg, Clopidogrel 75mg, Metoprolol XL 50mg, Isosorbide mononitrate 30mg, Atorvastatin 40mg, Ranitidine 300mg
  • Coronary angiogram revealed 2 V CAD; 95% prox RCA, 100% distal RCA BMS ISR and distal vessel fills via LAD collaterals, 90% mid LAD with LVEF 60% and Syntax score of 16.
  • Planned for IVUS/OCT guided rotational atherectomy and staged PCI of CTO RCA

Case Description

Pre Angiogram

PCI Strategy

  • ISR CTO length ~ 10-15mm with Collateral ++
  • Type: BMS ISR CTO
  • Antegrade approach with AWE (Fielder/FineCross > MiracleBros or Gaia > Confianza 12)
  • May require Rotational Atherectomy for lesion modification with extra support Rotawire

STEPS

  • First, we used Fielder and FineCross microcatheter.
  • Then the wire was exchanged to MiracleBros 6 (Open Coil, Straight tip, high tip stiffness > facilitate for drilling) together with FineCross microcatheter.
  • Finally, MiracleBros 6 (Tip load of 8.8g) crossed the CTO.

Wiring Technique

STEPS

  • Then, we exchanged MiracleBros with extra support Rotawire to perform rotational atherectomy (RA) with 1.5 burr.
  • Extra support Rotawire has longer spring tip (2.8 cm) compared to Rota floppy (2.2cm) with shorter wire transition at the tip.
  • After RA and atherotomy using flextome 3.25/6mm, three DES (3.5/32mm, 3.5/38 mm, 2.5/24mm) were placed in proximal, mid and distal RCA with an excellent result.

Wire Selection in Rotational Atherectomy

Final Angiogram

Learning Points

  • In BMS/DES ISR CTO intervention, the presence of stent will help in wiring step and may not require dual injection.
  • A stiffer wire with higher tip load is mostly required to go through ISR CTO segment and could use MiracleBros 6, Gaia 3, or Pilot 200T.
  • Rotawire selection is paramount and Rotawire Extra Support is particularly useful in ostial lesion, distal and angulated lesion.
  • One should have a low threshold to use an additional atherotomy as needed, even after rotational atherectomy performed.

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)              
681215202530
MINI TREK (CTO INDICATED)1.271.2
1.561.5
2.172✓*✓*
TREK2.372.25
2.672.5
2.912.75
3.113
3.53.25
3.73.5
3.943.75
4.324
4.864.5
5.365
*Only available as RX, not as OTW. Other sizes available in both versions.
Retrieved on April 07 2022 from Abbott product ordering information. Please look at the company's files for the latest available data on device configurations and avilability in your area.

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