Author + information
- Received October 19, 2018
- Accepted October 30, 2018
- Published online February 18, 2019.
- Massimo Medda, MD,
- Francesco Casilli, MD∗ (, )
- Marta Bande, MD and
- Maurizio Tespili, MD
- Interventional Cardiology Department, Istituto Clinico S. Ambrogio, Cardio-Thoracic Center, Gruppo San Donato, Milan, Italy
- ↵∗Address for correspondence:
Dr. Francesco Casilli, Interventional Cardiology Department, Sant’Ambrogio Cardio-Thoracic Center, Gruppo San Donato, Via Faravelli 16, 20149 Milan, Italy.
- bilateral radial approach
- left main stem bifurcation
- percutaneous coronary intervention
- rotational atherectomy
The treatment of choice for severely calcified, nondilatable coronary lesions is plaque debulking with rotational atherectomy (RA) followed by stent implantation (1). RA might also be applied in selected cases of coronary bifurcations (2).
We present the case of a 74-year-old patient with unstable angina, 3-vessel coronary artery disease, and heavily calcified distal left main coronary artery (LM) stenosis involving the bifurcation (Figure 1A, Online Video 1). The SYNTAX score was >32, but due to important comorbidities (chronic lymphatic leukemia B undergoing chemotherapy complicated by chronic kidney disease with serum creatinine of 4.2 mg/dl) after discussion of the heart team the patient underwent percutaneous coronary intervention. We performed a bilateral transradial approach with 2 6-F guiding catheters (GC) and performed RA (1.25 mm and 1.5-mm burr) on the LM–left anterior descending coronary artery axis; a guidewire had been placed in the dominant circumflex artery through the second GC, inside a 130-cm microcatheter protecting it from wire entrapment with burr rotation during RA and allowing rapid access to the side branch (SB) (Figure 1B, Online Videos 2 and 3). The LM was treated by implanting drug-eluting stents using the “culotte” technique, obtaining a good angiographic result (Figures 1C and 1D, Online Videos 4 and 5). We alternatively engaged the GCs in the LM to avoid potential vessel trauma and/or blood flow blockage.
The “double-GC technique” was previously described to optimize coronary hemostasis and to deliver coronary graft stents in case of coronary iatrogenic perforation (3). To our knowledge, this is the first case of effective and safe application of the double-GC technique to treat a calcified distal LM using RA. The advantages of this technique are SB protection with the ability to easily engage and treat the SB, prevention of SB wire entrapment during burr rotation (higher risk using a single larger GC), and the possibility of treating also the SB with RA by inverting the devices inside the catheters (Figure 2). Moreover, the transradial approach allowed us to avoid using a larger sheath (≥8-F) in the femoral arteries, reducing the risk for potential vascular and hemorrhagic complications.
In conclusion, the “protected” double-GC RA technique may allow safe and effective treatment of very calcified LM coronary bifurcations.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 19, 2018.
- Accepted October 30, 2018.
- 2019 American College of Cardiology Foundation