Case 15: Rotational Atherectomy and DES of CTO RCA BMS ISR
- 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
- 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
- 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.
- 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
The case can be reviewed at https://ccclivecases.org/june-2016-ccc-live-case
- 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.