A 65-year-old male patient presented for elective percutaneous coronary intervention of a heavily calcified mid left anterior descending (LAD) bifurcation lesion (Medina 1.0.1) due to angina pectoris (CCS II) despite optimal medical treatment.
The interventional procedure: A right radial approach was adopted using a 7 Fr sheath and an EBU 3.0 guide catheter. Wiring of the LAD with BMW wire was followed by IVUS evaluation of the lesion (Figure 1). ROTAWIRE was introduced into the LAD followed by rotational atherectomy (RA) using a 1.5 Burr at 180000 rpm. Then we advanced a BMW wire in the LAD beside the ROTAWIRE, leaving it as a buddy wire. A second BMW wire was advanced in the diagonal branch (D1). Sequential pre-dilatation of the LAD by NC balloons followed by LAD stenting with an Onyx Trustar DES 3.5 x 30 mm was done (Figure 2). Unfortunately, the ROTAWIRE was not removed before stenting, and was jailed between the stent and the calcified vessel (Figure 3a). After removal of the ROTAWIRE, we noticed longitudinal stent deformation (LSD) (Figure 3b). Enhanced stent visualisation technique showed that the distal two-thirds of the stent was deformed into a metal ball. At this point, we had a BMW wire in the D1 jailed behind the stent struts, and yet another BMW wire in the distal LAD jailed within the metal ball.
The first step involved attempting to pass multiple small, low-profile balloons, including CTO balloons, over the BMW wire to cross the deformed stent; however, all attempts failed. The second step was increasing guiding support with a guide-catheter extension and trying to advance a Sapphire Balloon 0.85x6 mm- but it also failed to cross. The third step involved attempting to cross the deformed stent through a new location or newly crushed strut using a polymer-jacketed wire (Fielder XTA®). To prevent the wire from passing beneath the proximal one-third non-crushed, underexpanded stent segment, we used a dual-lumen microcatheter (Nhancer®) (Figure 3c). However, attempts to cross the deformed stent with balloons were unsuccessful. Step four involved attempting to cross the deformed stent as far as possible with the smallest torquable microcatheter (Corsair Pro XS®). The microcatheter was partially advanced into the metallic ball, after which the Fielder XTA® wire was exchanged for a Rotawire Drive Floppy®, which easily crossed the deformed stent into the distal LAD (Figure 3d). Rotational atherectomy was performed using a 1.25 mm burr at 200,000 rpm. The burr successfully ablated the stent; however, it became stuck during the third run. The burr had to be removed by advancing the guide extension deeply to extract the burr and wire as a single unit (Figure 4). A Runthrough wire was introduced in the distal LAD, followed by step-wise sequential dilatation and crushing the deformed stent using NC Balloon. Re-Stenting the LAD was done with 3.5 x 30 mm Onyx Trustar DES at 14 Atm, followed by proximal optimization technique with 4 x12 mm NC Balloon with good result (Figure 5). Three months later, a follow-up coronary angiography was performed and revealed a good result (Figure 6).
