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Case 9: Protected PCI of complex calcified LAD using OA and DES with Impella LV assist

Case Presentation

  • A 73-year-old man presented with angina chest pain. Stress MPI showed anterior and inferior ischemia while planning for lower limb vascular surgery.
  • PMH: Extensive PAD s/p multiple PTAs, HTN, HLD, s/p MI
  • Medications : Plavix 75mg, Apixaban 5mg daily, Rosuvastatin 20mg, Isosorbide Mononitrate 30mg, Furosemide 20mg PRN
  • Coronary angiogram showed 2V CAD : 100% prox RCA occlusion with collaterals from LCx, 80-90% calcified angulated prox-mid LAD lesion.
  • Syntax score 23 and LVEF 30%.
  • Underwent Heart team discussion and decided for Impella assisted LAD PCI.

Angiogram

STEPS

  • Given the presence of severely calcified lesion in LAD, we had decided to perform lesion modification with orbital atherectomy (OA).
  • To wire the calcified artery, the wire should possess excellent support, good tactile feedback, floppiness, and torquability/trackability.
  • We used Fielder/FineCross to cross LAD lesion and then exchanged to ViperWire for OA.

LAD wiring and OA

  • After OA done, rewired the LAD with a workhorse wire (i.e. Runthrough) and polymer jacketed wire (i.e. Fielder) to Diagonal 3.
  • Provisional strategy was performed with the placement of 1 DES (Xience 3/38) in mid LAD, jailing Fielder wire in D3.
  • The jailed wire, Fielder, was removed from D3 and post dilatation in proximal part of the stent was performed with noncompliance balloon 3.5/15mm.
  • IVUS showed good distal stent apposition.

Stenting and Optimization

Final Angiogram

Learning Points

  • To negotiate a severely calcified artery, the wire should possess a good support, excellent tactile feedback, floppiness, and torquability/trackability.
  • The choice of wire should be Fielder, Whisper ES, and Pilot 50.
  • In case where you need more wire support for device delivery, we can exchange to Iron man or Mailman after the lesion is crossed and lesion modification performed.
  • We used orbital atherectomy in this case. However, if one wants to use rotational atherectomy, strongly recommend to use a smaller burr (1.25) in a calcified and tortuous lesion.

Left Main DK Crush Video ID