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

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.

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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