Title : Mastering complexity: successful management of high-risk dual CTOS with synergistic double calcium modification
Abstract:
Introduction: In the realm of percutaneous coronary intervention (PCI), the management of coronary artery calcium poses a significant challenge, particularly in cases of severe calcification and high-risk patients. Inadequate addressal leads to suboptimal outcomes in terms of stent delivery, expansion, and apposition, and increased risk of complications. Managing double chronic total occlusions (CTOs) in a single patient during a single procedure presents a formidable challenge in interventional cardiology, fraught with inherent risks and potential complications.
Case Presentation: We present a challenging case of a 55-year-old male with a five-year history of gradually progressive angina, hypertension, and smoking, culminating in Canadian Cardiovascular Society (CCS) Class IV angina over the past three months. Electrocardiography revealed ST depression in multiple leads and ST elevation in aVR, indicative of significant coronary artery disease. Echocardiography demonstrated preserved left ventricular function without regional wall motion abnormalities. Coronary angiogram revealed triple vessel coronary artery disease. Thorough procedural planning was done prior to the case after shared decision making with the family. The patient underwent a complex percutaneous coronary intervention (PCI) procedure with opening of both the CTOs. The right coronary artery (RCA) was prioritized, initially approached with a Gaia 2 wire and NIC nano balloon (0.85mm), and subsequently exchanged with a Fielder FC wire using a Finecross microcatheter. Despite successful crossing of the proximal chronic total occlusion (CTO) segment, encountering a distal cap branch presented a wiring challenge, necessitating branch occlusion with another wire for distal RCA access. Intravascular ultrasound (IVUS) imaging revealed extensive calcification of nearly 300 degrees in the CTO segment. Rota-ablation (Rota-pro) using 1.5mm burr followed by intravascular lithotripsy (IVL) were used prior to deployment of two overlapping stents. Similar calcium burden was observed in the left anterior descending artery (LAD) with 270-degree arc of calcium on IVUS, which was wired with Fielder XT-A wire. After pre-dilatation, Rotaablation followed by IVL were performed which enabled passing of two long stents which were successfully deployed. The left circumflex artery (LCX) lesion also had significant calcification which was similarly managed with predilation followed by intravascular lithotripsy (IVL) and stent deployment. Post-PCI the proximal LAD CTO segment achieved an area of 9.4 mm2, highlighting successful intervention despite challenging anatomical obstacles.
Discussion: This case underscores the effectiveness of multivessel PCI as a viable alternative to coronary artery bypass grafting (CABG) in patients with complex coronary anatomy and refractory angina. The integration of advanced technologies, meticulous planning, and procedural expertise played pivotal roles in achieving successful revascularization.
Conclusion: Multivessel PCI, supported by cutting-edge technologies and strategic planning, offers a compelling therapeutic option for patients with extensive coronary artery disease and refractory angina. This case exemplifies the transformative impact of technology like rota-ablation, IVL and CTO specific hardware, in overcoming challenges associated with chronic total occlusions and underscores the importance of a comprehensive approach in optimizing outcomes for high-risk patients.
Audience Take Away:
- The audience will gain valuable insights from the presented case on the effective management of complex coronary artery disease, particularly in patients with CTOs and extensive calcification. They will learn about the integration of advanced technologies such as rota-ablation, intravascular lithotripsy (IVL), and specialized hardware to achieve successful revascularization. This knowledge can be applied in their clinical practice to optimize procedural planning and execution in similar challenging cases, ultimately improving patient outcomes
- This case will significantly benefit the audience in their job by providing practical strategies and techniques for addressing complex coronary lesions, especially in patients with refractory angina and multiple CTOs. Healthcare providers involved in interventional cardiology, including interventional cardiologists, cath-lab staff, and allied healthcare professionals, can utilize the insights gained from this case to enhance their procedural skills, refine their decision-making processes, and improve patient care delivery
- Yes, this research can serve as a valuable resource for other faculty members to expand their research or teaching endeavors in interventional cardiology. The detailed presentation of the case, including procedural techniques, imaging findings, and clinical outcomes, offers a rich educational resource for teaching medical students, residents, and fellows about the complexities of managing complex coronary artery disease
