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
The case can be reviewed at https://ccclivecases.org/june-2019-ccc-live-case
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.
