ENCORE Hospital, Aparecida de Goiânia, Brazil.
ENCORE Hospital, Aparecida de Goiânia, Brazil.
Rev Port Cardiol (Engl Ed). 2020 Nov;39(11):673.e1-673.e6. doi: 10.1016/j.repc.2018.03.017. Epub 2020 Nov 6.
A 71-year-old man with Chagas disease and stable angina on minimum exertion underwent coronary computed tomography angiography and cine angiography that revealed heavily calcified multivessel disease involving the left main artery (LM). Due to the degree of calcification, it was decided to perform rotablation. The first-stage percutaneous coronary intervention (PCI) with rotablation was performed on the LM, left anterior descending artery and second diagonal branch without complications. Almost 30 days later he returned for right coronary artery (RCA) PCI. The proposed strategy was rotational atherectomy in the posterior descending artery (PDA) and right posterolateral artery (RPLA) with a 1.5 mm burr, followed by implantation of two drug-eluting stents (DES). Through right femoral artery access the RPLA lesion was ablated with success. As there were no signs of dissection and TIMI 3 flow was maintained, the 0.009″ RotaWire was repositioned to cross the PDA lesion and debulking of the lesion was performed. After two attempts we succeeded in crossing the lesion with the 1.5 mm burr, however entrapment of the burr ensued. The system was pulled back until the guiding catheter penetrated deep into the RCA, and attempts were made to release the Rotablator by moving it forward and backward, but the burr did not even spin. The contralateral femoral artery was therefore punctured and a 6F JR guiding catheter was inserted, in order to move a guidewire and small angioplasty balloon tangentially to the burr, but without success. Finally we advanced the guidewire using the 'knuckle' technique, taking advantage of the kinking of the distal portion of the PT2 guidewire, performing a subintimal dissection and re-entry, and could then easily cross the balloon, inflate it and release the trapped burr. Through the 6F system, two programmed and one bailout DES were successfully implanted in the PDA, RPLA and RCA, obtaining final TIMI 3 flow without complications.
一位 71 岁的男性，患有恰加斯病和稳定型劳力性心绞痛，接受了冠状动脉计算机断层血管造影和电影血管造影检查，结果显示多支血管严重钙化，累及左主干（LM）。由于钙化程度严重，决定进行旋磨术。LM、前降支和第二对角支的第一阶段经皮冠状动脉介入治疗（PCI）采用旋磨术，无并发症。近 30 天后，他因右冠状动脉（RCA）PCI 而返回。拟议的策略是在 PDA 和 RPLA 进行旋磨术，使用 1.5mm 磨头，然后植入两个药物洗脱支架（DES）。经股动脉入路，成功消融 RPLA 病变。由于没有夹层的迹象，并且 TIMI 3 血流保持通畅，重新定位 0.009″RotaWire 以穿过 PDA 病变，并对病变进行斑块切除术。我们尝试了两次，成功地用 1.5mm 磨头穿过了病变，但磨头被卡住了。系统被拉回，直到导引导管深入到 RCA 中，试图前后移动 Rotablator 以释放磨头，但磨头甚至没有旋转。因此，穿刺对侧股动脉，插入 6F JR 导引导管，以便沿磨头切线方向移动导丝和小血管扩张球囊，但没有成功。最后，我们利用 PT2 导丝远端的弯曲，采用“指节”技术推进导丝，进行内膜下夹层和再入，然后可以轻松地穿过球囊，充气并释放被困的磨头。通过 6F 系统，成功地在 PDA、RPLA 和 RCA 中植入了两根程控和一根挽救性 DES，最终获得了无并发症的 TIMI 3 血流。
