Staged percutaneous angioplasty of a long calcified left anterior descending artery with rotablation in a patient with stable angina

A 68-year-old female patient was admitted to the Department of Interventional Cardiology for the next stage of percutaneous coronary intervention (PCI) of a long, heavy calcified lesion in the left anterior descending (LAD) artery. The patient was treated for arterial hypertension, dyslipidemia and diabetes mellitus type 2. One month prior to admission, the patient underwent PCI of the circumflex artery. The patient still reported symptoms of stable angina (class II according the CCS classification).
The procedure was performed using right radial artery access. Distal parts of the LAD and diagonal branch (Dg2) were secured using Sion Blue guidewires. All of the compliant and non-compliant (NC) balloons starting from 2.0/20 mm, NC Emerge 2.5/15 mm and NC Emerge 3.0/15 mm with pressures up to 26 atm were used for pre-dilatation and crushed during the inflation. A strongly calcified, critical narrowing in the LAD was still present. The first attempt at delivering the Flextome Cutting Balloon 2.5/15 mm using the buddy-wire technique was unsuccessful. Introduction of the GuideLiner catheter facilitated inflation of the Flextome Cutting Balloon 2.5/15 mm. Due to the persistent, calcified narrowing with no improvement, the operator decided to perform the rotablation procedure. The RotaWire was introduced to the distal part of the LAD and 4 passages of Burr 1.5 160000 rpm (8 s in duration each) were performed. The next inflations of the Flextome Cutting Balloon with pressures of 6–12 atm and NC Emerge 3.0/8 mm with pressures of 18–24 atm were made. The effect was suboptimal with residual stenosis of 70%. Due to the large dose of contrast infusion, prolonged radiation time, and clinically and angiographically stable condition of the patient, the procedure was terminated.
Five days later, the next attempt via right femoral access with a 7 Fr catheter was performed. The distal part of the LAD was secured using Extra Support Rota-Wire. Three passages with Burr 1.75 mm 160000 rpm and another 3 passages of Burr 2.0 mm 160000 rpm (8 s in duration) were needed. Inflation of the NC balloon 3.0/15 mm with a pressure up to 20 atm was made, finally achieving successful pre-dilatation of the LAD. Angiography revealed linear dissection in the mid LAD. The first attempt at stent delivery was unsuccessful but the use of the GuideLiner catheter facilitated implantation of the Orsiro 3.0/40 mm stent in the mid LAD (10 atm). The dissection was fully covered. Next, the...


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