Successful Rotational Atherectomy of an Undilatable Ostial Saphenous Vein Graft Lesion

J INVASIVE CARDIOL 2020;32(8):E219. 

Key words: cardiac imaging, rotational atherectomy

A 66-year-old man with prior chest radiotherapy, coronary bypass graft surgery, percutaneous coronary intervention, and aortic valve replacement presented with chest pain. The electrocardiogram revealed ST elevation in avR, V1-3 with ST depression in I, II, avL, V4-6. Troponin was 3.1 ng/mL. Transthoracic echocardiogram demonstrated left ventricular ejection fraction of 50%-55%.

Emergent cardiac catheterization showed chronic total occlusion of the left main and proximal right coronary artery (RCA) and an atretic left internal mammary graft to the mid left anterior descending artery. The saphenous vein graft (SVG) to the first obtuse marginal was patent. The SVG to the distal RCA had severe ostial stenosis (Figure 1A; Video 1).

Engaging the SVG to RCA was challenging due to stent underexpansion, but eventually successful using a multipurpose diagnostic catheter to insert a Grand Slam guidewire (Asahi Intecc), followed by exchange for a 7 Fr multipurpose guide catheter. Inflation of 2.5 and 3.0 mm balloons and a 3.0 Angiosculpt (Philips) failed to expand the lesion. Intravascular ultrasound showed severe calcification (Figure 1B; Video 2). A temporary transvenous pacemaker was inserted and rotational atherectomy was performed with a 1.5 mm burr (Figure 1C; Video 3). The lesion was crossed after 13 runs. Multiple balloon dilations were performed (Figure 1D; Video 4), causing transient hypotension, and a 3 x 30 mm drug-eluting stent was deployed at 26 atm, achieving a good result with TIMI 3 flow (Figure 1E; Video 5). Echocardiography after 1 month demonstrated ejection fraction improvement.

View the Supplemental Video Series Here.

From the Minneapolis Heart Institute Foundation and Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Brilakis reports consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor, Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; research support from Regeneron and Siemens; shareholder: MHI Ventures. The remaining authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted February 4, 2020.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 East 28th Street #300, Minneapolis, MN 55407. Email: esbrilakis@gmail.com