Live case #6 : Lésion calcifiée en OFDI

This month, we present the case of an 80 years old male patient, smoker, known to have HFrEF secondary to a cardiac amyloidosis TTR s/p CRT-D, severe aortic stenosis (ASA 0.6 cm2), hypertension, dyslipidemia and chronic kidney disease.

Coronary angiography pre-TAVR revealed: dominated RCA that is occluded as well as a moderate lesion of the obtuse marginal and severely calcified lesions of the proximal and mid LAD that is occluded distally.

Educational objectives

• How to manage a high-risk patient with multiple co-morbidities.
• Plan a step-by-step approach procedure for calcified lesion preparation and stenting.
• Choice of material: introducer size, guidewires, guide extension, choice of lesion modifying technique/tools.
• Role of intravascular imaging.

Step-by-step procedure:

1) Access site and hemodynamic stability:

• Right radial approach: 7 French EBU 3.5 to the left main.
• Under Dobutamine IV infusion.
• Anticoagulation using heparin.

2) Intravascular imaging:

• Two 0.014” Sion Blue (Asahi) guidewires for extra support were introduced into the LAD.
• Intravascular imaging using optical frequency domain imaging (OFDI) (Terumo) at 40 mm/sec in order to minimize contrast injection showed superficially calcified LAD with several calcified nodules at the mid-LAD level and 360° calcium rings.

3) Calcium modifying device:

• Intravascular lithotripsy using a 3.5 x 12 mm Shockwave balloon was selected and the mid-LAD and proximal LAD lesions were predilated.
• Upon balloon inflations, a drop of blood pressure was noted, a small dose of Noradrenaline was set up.
• Further lesion preparation using a non-compliant balloon 3.5 mm inflated up to 20 atm was done at the level of the mid and proximal LAD lesions.

4) LAD stenting:

• A 3.5 x 21 mm Nagomi Ultimaster (Terumo) stent could not cross the proximal LAD lesion.
• A 6 French (due to out-of-stock 7 French) Boosting guide extension catheter (QX Medical) was introduced to the mid-LAD and facilitated stent delivery to the mid-LAD lesion that was inflated to 16 atm.
• Using the stent balloon, the guide extension catheter was advanced into the recently implanted stent.
• A 4.0 x 33 mm Nagomi Ultimaster (Terumo) was then implanted to cover the proximal LAD lesion and inflated to 16 atm.

5) Stent optimization:

• An OFDI run was performed at this time in order to assess the implanted stents and showed stent malapposition at different levels as well as a small dissection.
• Post-dilatation of the distal stent using a 4.0 mm non-compliant balloon inflated at 20 atm followed by a post-dilatation of the proximal stent using a 4.5 mm non-compliant balloon inflated at 20 atm were performed.
• The angiographic end-result was perfect.

6) Post-procedure patient care:

• Dobutamine tapering to stop over the next hour.

Bibliography