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Case 24: Complex PCI of Tortuous Calcified RCA Using Rota With Guide Extension Support

Case 24: Complex PCI of Tortuous Calcified RCA Using Rota With Guide Extension Support

Case Presentation

A 43-year-old man presented with angina chest pain and dyspnea on exertion.
PMH: Hyperlipidemia, IDDM, h/o MI, h/o CVA without deficit, positive lupus anticoagulant, ESRD on hemodialysis
Medications: Aspirin, Metoprolol XL, Isosorbide Mononitrate, Atorvastatin, Losartan, Nifedipine, Insulin, Warfarin

LHC revealed severely calcified 2 V CAD: 90% mid LAD, multiple calcified 80-99% lesions in extremely tortuous RCA, and LVEF 55%.
He underwent PCI of LAD with an excellent result.
Since RCA is extremely tortuous and severely calcified, plan to use lesion modification probably rotational atherectomy with guide extension catheter.

We used 7F AL 0.75 guide catheter via femoral approach.
To perform rotational atherectomy, we used Fielder and FineCross microcatheter to negotiate the lesion then exchange to RotaWire Extra Support.
However, there was significant wire bias once Rota burr was attempted to advance into the RCA.

There is significant RotaWire bias (black arrow) which prevents from advancing the Rota burr.

RotaWire Floppy Guidewire

Used in 75% of cases
First line wire due to:
- Significantly reduced guidewire bias
- Spring tip (2.2 cm)

RotaWire Extra Support Guidewire

A stiffer frontline wire for:
- Distal lesions
- Heavily calcified proximal lesion
- Spring tip (2.8cm)

Then, we decided to exchange from RotaWire Extra Support (0.009 core diameter with tip diameter of 0.014”, and short core taper) to Rota Floppy wire (0.009 core diameter with tip diameter of 0.014”, and long core taper) to reduce wire bias.
Rotational atherectomy with 1.75 burr was performed in midRCA without any difficulty.
For distal RCA lesion, we use 7F guide extension catheter (Guidezilla) to perform rotational atherectomy using 1.25 burr.

After RA of mid and distal RCA/RPL, PTCA and two DES were placed in mid RCA (Xience 4/23) and dRCA/RPL (Xience 2.5/38) with an excellent result.

In complex calcified tortuous lesion intervention, an excellent guide support is paramount.
The operators couldn’t emphasize more about the awareness of Rotawire bias and must exchange to Rota Floppy wire if there is significant wire bias to prevent untoward complications.
The main difference between Rotawire Floppy and Extra Support is length of core tapering (13cm vs 5cm).
Here, we exchanged Rotawire Extra Support to Floppy wire.
In a tortuous lesion and complex CTO intervention, a guide extension catheter could help to deliver various devices to the distal segment. Through 7F guide extension catheter, Rota burr ≤ 1.5 can be used^[1-3].
The operators need be to familiar with various techniques of advancing the Rota burr into the distal lesion to perform calcified complex coronary intervention.

Kovacic, J. C., Sharma, A. B., Roy, S., Li, J. R., Narayan, R., KIM, D. B., … & Kini, A. S. (2013). GuideLiner mother‐and‐child guide catheter extension: A simple adjunctive tool in PCI for balloon uncrossable chronic total occlusions. Journal of interventional cardiology, 26(4), 343-350.
Senguttuvan NB, Sharma SK, Kini A. Percutaneous intervention of chronic total occlusion of anomalous right coronary artery originating from left sinus – Use of mother and child technique using guideliner. Indian Heart J. 2015 Dec;67 Suppl 3(Suppl 3):S41-2. doi: 10.1016/j.ihj.2015.10.300. Epub 2016 Jan 18. PMID: 26995429; PMCID: PMC4799001.
Bharadwaj AS, Bhatheja S, Sharma SK, Kini AS. Utility of the guideliner catheter for percutaneous coronary interventions in patients with prior transcatheter aortic valve replacement. Catheter Cardiovasc Interv. 2018 Feb 1;91(2):271-276. doi: 10.1002/ccd.27211. Epub 2017 Aug 10. PMID: 28795527.