A coronary “tunnel”: Optical coherence tomography assessment after rotational atherectomy

Abstract

A 81-year-old woman was admitted for exertional angina. Coronary angiogram revealed a severely calcific proximal circumflex lesion. Rotational atherectomy was performed with 1.5 and 1.75 burrs, obtaining a good angiographic result. Optical coherence tomography (OCT) assessment revealed a large dissection parallel to the true lumen. We implanted a 3.0 mm × 38 mm Xience Prime(®) stent and postdilated it with a 3.0-mm non-compliant balloon. Final OCT pullback showed mild malapposed struts with large lumen area. 3D-OCT reconstruction confirmed a large lumen after stent implantation.

Optical coherence tomography assessment of the mechanistic effects of rotational and orbital atherectomy in severely calcified coronary lesions

“…A few OCT case reports have demonstrated that RA yields a relatively smooth luminal surface with cylindrical geometry and that lumen enlargement occurs mainly by selective ablation of inelastic plaque without significant arterial expansion . In regions of tortuosity or eccentric plaque, crater, or tunnel formation could occur after RA , which may lead to perforation or stent malapposition . Deep dissection occurred in 30% after RA and 40% after OA, but the deep dissections were more extensive after OA, which we termed lacunae.…”

Safety and effectiveness of coronary intravascular lithotripsy in eccentric calcified coronary lesions: a patient-level pooled analysis from the Disrupt CAD I and CAD II Studies

“…All other debulking techniques (Cutting-/Scoring-Balloon, atherectomy techniques) may suffer from guidewire bias leading to inhomogeneous plaque modification [9,[19][20][21]. OA and RA modify calcified plaque by generating a relatively smooth, circular channel, strictly following the guidewire [19,[21][22][23][24]. This facilitates balloon or stent delivery, although the gain in the cross-sectional area is modest [24].…”

Effect of cutting balloon after rotational atherectomy in severely calcified coronary artery lesions as assessed by optical coherence tomography

“…Intravascular ultrasound (IVUS) studies have demonstrated that the mechanisms of lumen gain after angioplasty consists of two major components: Plaque modification (fracture or redistribution) and arterial expansion; however, severe circumferential calcification cannot be dilated easily compared with noncalcified lesions, and OCT studies have shown that calcium fracture is associated with better lumen gain after PCI in severely calcified lesions . RA modification of calcified plaque might overcome these problems by improving lesion compliance to allow more uniform stent expansion . The Rotational Atherectomy Prior to Taxus Stent Treatment for Complex Native Coronary Artery Disease (ROTAXUS) trial reported that acute gain was greater with RA prestenting compared with balloon predilation only; however, angiographic late loss and major adverse cardiac events at 9 months were not significantly improved …”

“…Although drug‐eluting stents (DESs) have improved the outcomes of patients with complex coronary artery disease undergoing percutaneous coronary intervention (PCI), severely calcified lesions remain a challenge due to a higher prevalence of stent delivery failure, stent under‐expansion, and subsequent restenosis . Rotational atherectomy (RA) is effective for modification of calcified plaque to facilitate crossing with any device and to improve stent expansion . Preliminary reports have shown the efficacy of cutting balloons (CBs) compared with conventional balloons as a substitute for or as part of combination therapy with RA for severely calcified coronary artery lesions .…”