Angioplasty of a Severely Calcified RCA in the Context of an Acute Coronary Syndrome

Dr. Marek Jankiewcz

Puławy. Poland

Introduction

Calcified lesions remain one of the main challenges in interventional cardiology, especially in the treatment of acute coronary syndromes (ACS). These lesions often require combined plaque modification techniques, such as rotablation, intravascular lithotripsy (IVL), and cutting balloons, to allow optimal vessel dilation and effective stent implantation.
The use of a microcatheter in these procedures is crucial, as it allows overcoming functional stenoses, facilitating the crossing of specialized guidewires, and optimizing lesion preparation. This case describes the percutaneous treatment of a critically calcified stenosis in the right coronary artery (RCA), highlighting multiple challenges during the intervention, including the need for rotablation after the failure to deliver a stent, leaving a gap in coverage in the mid-segment of the vessel.

Patient Profile

70-year-old male.
Active smoker, with a history of hypertension.
Reason for admission: Recurrent chest pain with elevated myocardial necrosis markers, diagnosed as acute myocardial infarction (AMI).
Coronary angiography findings:
- Severely calcified stenosis in the right coronary artery (RCA).
Candidate for percutaneous coronary intervention (PCI).

Lesion Type

Severe stenosis with concentric calcification in the RCA.
Difficulty in lesion preparation and device delivery.
Failure in the implantation of the second stent, creating a gap in the mid-segment of the RCA.
Need for rotablation to allow successful stent placement.

Procedure

The procedure began with pre-dilation using a 2.0 mm balloon, followed by an intravascular ultrasound (IVUS) assessment, which confirmed the presence of severe concentric stenosis. An attempt was made to advance a 3.5 mm IVL balloon, but its delivery was unsuccessful due to lesion calcification.
To improve vessel navigability, plaque modification was performed using a 3.0x10 mm Naviscore cutting balloon in the mid and proximal RCA, which enabled successful delivery and activation of the IVL balloon at the lesion.
A first stent was implanted in the mid-segment of the vessel. However, during the implantation of the second stent, it slipped off the balloon, leaving a gap in the mid-segment of the RCA. Attempts to place another stent to cover the gap were unsuccessful, leading to the decision to perform rotablation.
To facilitate rotablation, the Navitian microcatheter was used, enabling the safe introduction of the Floppy rotablation guidewire into the true lumen of the vessel, avoiding wire passage through the struts of previously implanted stents. Eight rotablation cycles were performed using a 1.5 mm burr at 180,000 rpm, allowing complete dilation with a 3.5x18 mm NC balloon.
Following lesion modification, two additional stents were successfully implanted:
- In the mid-segment, covering the gap between the previous stents.
- In the proximal segment of the RCA.

Results

Successful revascularization with final TIMI 3 flow and resolution of patient symptoms.
200 mL of contrast used and a radiation dose of 300 mGy.
Peak troponin elevation: 13.
No haemoglobin drop or renal function impairment.

Conclusion

The use of the Navitian microcatheter had a direct impact on the safety and effectiveness of the procedure. Its ability to overcome functional stenoses and facilitate rotablation guidewire delivery enabled the successful revascularization of a severely calcified RCA. In this case, the microcatheter was the only viable solution to ensure safe wire placement and prevent complications, demonstrating its crucial role in PCI for complex calcified lesions.

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