OCT-Guided PCI With Rotational Atherectomy in a Heavily Calcified Bifurcation Lesion

The authors can be contacted via Dr. Annapoorna Kini at annapoorna.kini@mountsinai.org.

Clinical history

A 72-year-old male with controlled hypertension, hyperlipidemia, and noninsulin-dependent diabetes mellitus (NIDDM) was admitted with crescendo angina and a positive SPECT MPI showing inferoseptal ischemia.

Procedure

• Coronary angiogram demonstrated 80-90 percent stenosis in the mid left anterior descending coronary artery (LAD) and first septal (Figure 1A, arrow).
• Pre-percutaneous coronary intervention (PCI) optical coherence tomography (OCT) imaging revealed fibrocalcific plaque with three-quadrant calcification (asterisks) at the minimal lumen area site (MLA) (Figures 1B and 1C).
• OCT/angiography co-registration images detected heavy calcification distal to the MLA (Figure 2A) and mostly small, calcified deposits proximal to the MLA (Figure 2B).
• Rotational atherectomy (ROTA) was performed in the mid LAD using a 1.75mm burr at 150,000 rpm, followed by placement of a Xience Xpedition^™ drug-eluting stent (3.5x18.0mm).
• An OCT pullback was performed to evaluate stent expansion and apposition. Post stent OCT imaging detected good stent apposition (minimal stent area [MSA]=6.08mm²). Severe stent malapposition with the maximal vessel to strut distance of 320µm and 2.1mm length was observed at the proximal edge of the stent (Figure 3, arrows).
• Postdilatation with the Quantum Apex^™ 4x8mm balloon was performed.
• OCT imaging after postdilatation showed significant improvement of stent apposition (Figure 4).

Conclusions

Heavy calcification within coronary atherosclerotic plaque adversely influences both clinical and procedural success after PCI. In this case, OCT/angiography co-registration imaging not only confirmed the presence of calcium on the angiogram, but also provided detailed information on its extent and location, providing guidance for calcium ablation using rotational atherectomy. Detection of stent malapposition by OCT imaging led to postdilatation, which resulted in significantly improved strut apposition. 

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