The Rotational Atherectomy represents an option to improve the treatment of calcified/undilatable stenoses, but its use in ST-segment Elevation Myocardial Infarction (STEMI) is controversial. This report describes a patient with an occlusive and calcified coronary stenosis and its management not previously described. A 67-year-old man with STEMI was conduct to our cath-lab. The coronary angiography showed a complex calcified and thrombotic occlusion of right coronary artery. Vessel patency was obtained with balloon dilatation, achieving clinical stability. The patient started dual anti-platelet therapy and was scheduled to perform a staged-procedure using Rotational Atherectomy, accomplished six days later reaching optimal angiographic and clinical results. Our purpose was to manage this patient in two times: a primary coronary angioplasty to quickly reopen the artery and an early staged percutaneous coronary intervention (PCI) using the RA to optimize the intervention (coronary dilatation and stent deployment).

Keywords: acute myocardial infarction, case report, dual antiplatelet therapy, percutaneous coronary intervention, rotational atherectomy, ST-segment elevation myocardial infarction

ACS, acute coronary syndrome; AMI, acute myocardial infarction; DAPT, dual anti-platelet therapy; DES, drug eluting stent; LAD, left anterior descending (coronary artery); PCI, percutaneous coronary intervention; RA, rotational atherectomy; RCA, right coronary artery; STEMI, ST-segment elevation myocardial infarction; TIMI flow, thrombolysis in myocardial infarction flow

With increasing of population age and incidence of atherosclerotic diseases, coronary lesions of patients who come to our catheterization lab tend to be increasingly complex, including in ST-segment Elevation Myocardial Infarction (STEMI) patients.¹ Calcified coronary lesions represent a challenge for interventional cardiologists, because of the procedural technical difficulty compared to simple stenoses and due to their association with higher rates of procedural failure, stent under-expansion, lower post-procedural minimal luminal diameter and high rate of acute complications.² The management of these lesions becomes even more complex if it concerns patients in an acute setting, such as in the case of STEMI in which the thrombus burden is greater. In acute coronary syndromes (ACS) patients, the role of Rotational Atherectomy (RA), an intracoronary technique used in calcified lesions, is very controversial because of the potential complications³ and in particular few data are known on its use in STEMI patients, having been used only in a very few cases in the acute phase during the primary percutaneous coronary intervention (PCI).

This case report describes the management of a STEMI patient with an occluded but also heavily calcified coronary artery, divided into two different times: the primary PCI to quickly reopen the occluded artery, the early staged PCI to optimize the intervention using the RA.

A 67-year-old man was conduct to our primary percutaneous coronary intervention (PCI) service (Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, Catania, Italy) by the paramedic ambulance team for chest pain and inferior ST-segment elevation on his electrocardiogram (ECG). He was an ex-smoker, affected by mild systemic hypertension treated with ACE-inhibitor and beta-blocker, and his medical history included a previous acute coronary syndrome (ACS) treated with PCI with a drug eluting stent (DES) on left anterior descending (LAD) artery 7years earlier. With an established diagnosis of inferior ST-segment Elevation Myocardial Infarction (STEMI), the patient was brought to our cath lab and he was loaded with 300mg of Aspirin, 180mg of Ticagrelor and 8,000 IU of unfractioned heparine prior the catheterization. Coronary angiography was performed by right radial artery access with a 6 French sheath and 6 French catheters: the angiograms showed a good result of previous LAD-PCI and a complete occlusion of the mid right coronary artery (RCA) which appears as acute event, although the artery was tortuous and heavily calcified (Figure 1). At the beginning, a 6 French Judkins Right 4.0 guiding catheter was used to engage the RCA ostium. The lesion was crossed by an extra-back Sion Blue guidewire (Asahi Intecc, Nagoya, Japan); subsequently using the “buddy wire” technique with another Sion Blue guidewire, a semi-compliant balloon 1.5/15mm was inflated in the mid RCA but no anterograde flow was achieved. Due to the poor back up support, the guiding catheter was exchange with an Amplatz Left 1.0. The lesion was easily crossed the extra-back Sion blue guidewire and multiple dilatations with 2.0/20mm and 2.5/20mm semi-compliant balloons were performed, obtaining a complete restore of anterograde flow (Thrombolysis In Myocardial Infarction 3 flow -TIMI 3 flow-) (Figure 2), resolution of chest pain and ECG signs of ischaemia/lesion. Due to the stability of the patient and the resolution of the symptoms, the operator decided to stop the procedure and the patient was schedule to perform a staged-PCI procedure using rotational atherectomy (RA).

Figure 1 Basal Coronary Angiography A) Angiogram shows occlusion of right coronary artery in a left anterior oblique projection; B) Angiogram showing good result of previous stent implantation in mid left anterior descending in antero-posterior cranial projection.

Figure 2 Primary Percutaneous Coronary Intervention for quick reopening of occluded vessel A, B, C) Angiograms showing balloon dilatation through right coronary artery from proximal to distal segments; D) Angiogram showing final result after ballooning.

The patient was transfer to intensive coronary care unit, undergoing continuous monitoring of vital signs. The dual anti-platelet therapy (DAPT) with Aspirin 100mg plus Ticagrelor 90mg b.i.d. was administer; two-dimensional echocardiography showed a mild reduction of left ventricle ejection fraction (48%) with hypokinesia of inferior and infero-lateral walls, and mild mitral regurgitation.

Six days after primary PCI, the patient was brought back to the cath lab; engagement of RCA was performed with 6 French Amplatz Right 1.0 guiding catheter through left radial artery access. The coronary angiography confirmed a severe calcific thigh stenosis of the mid RCA and severe stenosis of the distal vessel segment. Using the new RotaPro Rotational Atherectomy System (Boston Scientific Corp.), RA was executed with the 1.5mm burr, advanced on the 0.009-inch floppy RotaWire guidewire (Boston Scientific Corp.), from proximal to the distal segment of RCA. Patient did not become hypotensive during the procedure, maintaining normal vital parameters. Then, multiple dilatations with 2.5/15mm AngioSculpt scoring balloon (AngioScore, Inc., Fremont, California, USA) and 3.0/20mm semi-compliant balloon were performed. Finally, five durable-polymer Everolimus eluting stents (Xience; Abbott Vascular, Santa Clara, California, USA) were implanted in overlapping from distal to proximal RCA (respectively: 2.5/22mm, 2.5/22mm, 2.75/26mm, 3.0/26mm, 3.5/38mm), with subsequent stent-deployment optimization using 3.0/20mm and 3.5/20mm non-compliant balloons, achieving an optimal angiographic result (Figure 3). The patient was discharge after 4days in good clinical health condition.

Figure 3 Rota-staged procedure to optimize the angiographic result using Rotational Atherectomy A) Angiogram showing the residual heavily calcified lesion of right coronary artery in a left anterior oblique projection; B, C, D) Fluoroscopy images showing the use of rotational atherectomy into the right coronary artery, from proximal to distal segment; E) Fluoroscopy images showing the balloon dilatation of the right coronary artery; F) Angiogram showing the final result with a totally patent right coronary artery after stent implantation and post-dilatation, with a TIMI 3 flow.

Calcified coronary lesions are a subset which presents many technical challenges; indeed their treatment is associated with higher rates of procedural failure, stent under-expansion, lower post-procedural minimal luminal diameter, high rate of acute complications such as acute dissection, restenosis and target lesion revascularization.² RA has been shown to increase procedural success in these lesions, facilitating balloon dilatation and stent delivery and ensuring complete stent expansion.⁴

Despite a well-established use in calcific stable coronary disease, the role of RA in ACS remains controversial through the literature. Indeed, its application in STEMI is little known, being its use contraindicated by the manufacturer in case of lesions with visible thrombus; thus, RA is traditionally avoided because of platelet activation and distal coronary embolization by rotating burr in high thrombotic states and the risk of no reflow.³

As populations aging, coronary lesions tend to be progressively complex also in STEMI patients,¹ requiring sometimes unconventional management. An increased use of RA in ACS patients was observed, including STEMI patients with patent culprit artery in absence of thrombus burden.⁵ Doshi et al.⁶ published a comparative study of RA in acute (269 patients) and stable (843 patients) coronary syndromes. This study showed higher rate of angiographic complications in the ACS group (p=0.02), in-hospital target vessel revascularization (p=0.01) and in-hospital death (p=0.057).

In 2005 Ho Paul C.⁷ published the first case on the successful utilization of rotational coronary atherectomy into an occluded LAD in the middle segment in the setting of acute myocardial infarction. Similarly, other authors published case reports about the successful use of RA in STEMI patients with heavily calcified and undilatable lesion and difficulty in advancing balloons across lesions, allowing the facilitation of stent expansion.^8,9

More recently, in 2018 Januszek and colleagues¹⁰ compared angiographic effectiveness and periprocedural complications in 221,187 patients undergoing PCI and RA was used in 530 patients with stable angina and 245 patients with AMI. The overall rate of periprocedural complications did not differ between two groups and among the two subgroups (RA and non-RA group) of AMI patients, and the angiographic success was significantly higher in RA group. The authors concluded that RA can be used during PCI in AMI patients, although the incidence of adverse events among STEMI was not specified, thus it is no possible to have a definite conclusion of the RA role in this setting.

According to our knowledge, we described for the first time a case of staged-use of RA in a STEMI patient. During the acute phase, we proceeded with the recanalization of the occluded coronary artery (TIMI 0 flow), achieving vessel patency with a TIMI 3 flow, allowing the coronary perfusion and obtaining a regression of the patient’s symptoms. Subsequently, six days after primary PCI, RA was performed, ensuring a safe and effective angioplasty. After the plaque debulking, the classical steps of angioplasty (pre-dilatation, stent implantation and post-dilatation) were possible, achieving an excellent final angiographic result without residual stenoses. This objective was obtained, also thanks to the reduced state of platelet aggregation and intracoronary thrombus burden related to full operating DAPT.

In our case, this strategy permitted a relatively “easy” and “quick” primary PCI procedure that allowed reducing myocardial necrosis related to the AMI. The operator decision to postpone the RA, was taken considering the fact that any severe procedural complication such as a coronary dissection or no-reflow during the acute phase of STEMI might lead to a very worse clinical outcome. Finally, we can conclude that the management of this patient respects the old medical adage “time is muscle”, ensuring a rapid vessel patency with a subsequent staged-procedure in order to optimize the PCI.

None.

The rest of the authors declare do not have conflicts of interest.

None.

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