Rotational atherectomy, jailed buddy wire and STAR to the rescue: A challenging PCI of a severely calcified circumflex

We present a case of an 88-year-old gentleman that was administered to our hospital with angina, that was refractory to medication, and progressive systolic heart failure. The patient had a history of severe coronary artery disease. Mitral- and aortic valves were patent. On diagnostic angiogram, the proximal and distal RCA showed moderate disease with a good result in the previously stented medial segment. The left main was without relevant disease and the medial LAD showed only moderate disease. The culprit appeared to be the circumflex (CX) with heavily calcified severe stenoses of the proximal and the medial segments. The lesions turned out to be balloon un-dilatable. Of note, the second obtuse marginal branch (OM) originated from the severely diseased medial circumflex without showing relevant disease on its own. Hence, we applied rotational atherectomy using a 1.5mm burr. Rotational atherectomy and subsequent balloon dilatation were straight forward. However, even after rotational atherectomy, stent delivery was challenging. We used the buddy wire and our trusted jailed buddy wire technique to deliver 4 highly flexible stents into the CX. Unfortunately, the rather large OM was compromised with TIMI II flow after placement of a stent into the medial CX. Attempts to rewire with workhorse wires remained futile and led to dissection of the vessel. The patient developed severe chest pain so that we went for antegrade dissection and re-entry to recanalize th OM. We successfully applied the subintimal tracking and re-entry (STAR) technique to recanalize the OM. After PCI and placement of a DES into the OM we achieved a nice angiographic result. Due to heavy calcification we decided against CX/OM bifurcation stenting. The patient had an uneventful recovery and was discharged the following day.