Surgical Clearance with Chocolate

A 72-year-old man was referred to our center to be cleared for spine surgery. He had a history of coronary artery disease (CAD), non-ischemic cardiomyopathy, congestive heart failure (CHF), aortic valve disease and chronic obstructive pulmonary disease (COPD). Risk factors included a family history of CAD, former tobacco use, hypertension, diabetes mellitus, and hypercholesterolemia. His medications included beta blockers, insulin, statin, and anti-anginal therapies. The risks, benefits and alternatives to the catheterization procedure were discussed with the patient, and informed consent was obtained.

The patient was prepped and draped in the usual sterile manner. Right femoral artery access was obtained, and a 4 French x 10 mm Pinnacle sheath (Terumo) was advanced into the vessel.  

A 4 French Judkins left (JL) 5.0 catheter (Terumo) was advanced into the left coronary artery ostium to obtain a selective left coronary angiography. The left main (LM) was found to bifurcate normally into the left anterior descending (LAD) and left circumflex (LCX) coronary arteries. The arteries were heavily calcified (Figure 1). There was an 80% de novo stenosis in the mid LAD (Figure 2). The LCX had non-obstructive disease.  

The catheter was exchanged for a 4 French 3DRC catheter (Cordis), which was advanced into the right coronary artery (RCA) ostium to obtain a selective right coronary angiography. The mid RCA had a 30% stenosis.

The right femoral artery sheath was then exchanged for a 6 French x 10 mm Pinnacle sheath. A 4 French pigtail catheter was advanced across the aortic valve to the left ventricle. Ejection fraction was estimated at 35% by visual assessment.

To access and treat the mid LAD lesion, the catheter was exchanged for a 6 French XBLAD catheter (Cordis). Bivalirudin was administered as a 16.5 mL bolus and at an infusion rate of 38.5 mL/hr. The lesion was crossed with a fractional flow reserve (FFR) wire (Volcano/Philips). Maximal hyperemia was achieved with intravenous adenosine, and the flow reserve (pressure-derived FFR) was calculated to be 0.75 (Figure 3).

Given the calcified morphology of the mid LAD lesion, we decided to dilate with a 2.5 x 20 mm Chocolate PTCA balloon (TriReme Medical/QT Vascular). The balloon was positioned across the lesion and inflated once to 12 atmospheres for 10 seconds (Figure 4).

The residual stenosis was 20% with an improved angiographic appearance and TIMI grade 3 flow. FFR was repeated and found to be normal at 0.88. No flow-limiting dissections or embolization were noted (Figure 5).

Since the patient was to undergo spine surgery, we preferred to avoid putting the patient on dual antiplatelet therapy (DAPT) if possible. If we were to place a stent, we would have to prescribe DAPT for this patient. After seeing the successful results of the PTCA intervention, we chose not to stent this lesion.

At the conclusion of the case, the right femoral artery was closed with a 6 French Angio-Seal VIP (St. Jude Medical).

The Chocolate PTCA balloon used in this case was chosen for its unique “pillows and grooves” design, created by its nitinol-constraining structure (Figure 6). Because of this unique design, it results in controlled inflation to minimize vessel wall trauma. In our experience, the Chocolate balloon helps us achieve predictable luminal gain even in complex plaque morphologies. When sized appropriately to the vessel, it has a low risk of causing flow-limiting dissections. This was particularly important in this case, as it allowed us not to stent and therefore not to put the patient on DAPT. 

Disclosure: Orlando Marrero reports he is a consultant for Boston Scientific. Dr. Stark reports no conflicts of interest regarding the content herein.
Orlando Marrero, RCIS, MBA, can be contacted at orlm8597@icloud.com. 

Dr. Stephen Stark can be contacted at sstark@citruscardiology.org