Abstract
We present herein the case of a delayed covered coronary wall rupture occurring as a rare complication of rotational atherectomy performed in the subintimal space after antegrade dissection reentry for percutaneous recanalization of a long and heavily calcified left anterior descending chronic total occlusion, which was successfully managed percutaneously with the implantation of 2 covered stents. (Level of Difficulty: Intermediate.)
Key Words: coronary angiogram, percutaneous coronary intervention, stents
Abbreviations and Acronyms: CA, coronary angiogram; COPD, chronic obstructive pulmonary disease; CTO, chronic total occlusion; LAD, left anterior descending artery; PCI, percutaneous coronary intervention
Graphical abstract
A 64-year-old man with arterial hypertension, dyslipidemia, and severe chronic obstructive pulmonary disease (COPD) was admitted to the hospital with stable angina. Diagnostic coronary angiogram demonstrated a long heavily calcified mid–left anterior descending artery (LAD) chronic total occlusion (CTO) (J-CTO score 4), a severe ostial intermediate artery stenosis, and a second marginal branch stenosis (Figure 1A, Video 1). The patient was turned down for surgery by the Heart Team because of severe COPD. After discussion, the patient agreed to undergo multivessel staged percutaneous coronary intervention (PCI). LAD CTO PCI was performed according to the hybrid algorithm. After unsuccessful anterograde wire escalation, the CTO was crossed using wire-based antegrade dissection and reentry technique, but was uncrossable with a 1.0-mm low-profile balloon (Video 2). After wire exchange through a microcatheter, intensive subadventitial plaque modification was performed using a 1.25-mm rotational atherectomy burr (Video 3) allowing subsequent progressive balloon crossing (Figure 1B). After predilatation using high-pressure noncompliant balloons, two 3.5 × 34-mm and 3.0 × 38-mm zotarolimus-eluting stents (Resolute Onyx, Medtronic Inc., Minneapolis, Minnesota) were successfully delivered to the proximal and mid-LAD with a good final angiographic result (Figure 1C, Video 4). Due to the complexity of the PCI performed for the CTO revascularization, control coronary angiogram was performed at 3 months and demonstrated 2 large areas of contrast extravasation at the site of previously implanted stents on proximal and mid-LAD, suggesting delayed covered coronary artery wall rupture (Figure 1D, Video 5). PCI to proximal and mid-LAD with 2 3.5 × 20-mm covered stents (PK Papyrus, Biotronik, Bülach, Switzerland) was performed with immediate complete disappearance of the contrast extravasation confirmed by coronary angiography (Figure 1E, Video 6). Six-month control coronary angiogram demonstrated patent covered stents and no residual contrast leakage (Figure 1F, Video 7).
Figure 1.
Baseline, 3-Month, and 6-Month Follow-Up Coronary Angiograms
(A) Baseline coronary angiography demonstrating a long heavily calcified mid-left anterior descending artery chronic total occlusion (white arrow), a severe ostial intermediate artery stenosis (black arrow) and a second marginal branch stenosis (blue arrow). (B) Successful left anterior descending artery chronic total occlusion crossing using antegrade dissection and reentry technique followed by subintimal plaque modification with rotational atherectomy. (C) Final angiographic result after implantation of 2 drug-eluting stents to proximal and mid-LAD. (D) Three-month control coronary angiography demonstrating large areas of contrast extravasation (black arrows) at the sites of previously implanted stents on proximal and mid- left anterior descending artery. (E) Final angiographic result after implantation of 2 covered stents on proximal and mid- left anterior descending artery. (F) Six-month control coronary angiography demonstrating patent covered stents and no residual contrast leak.
Rotational atherectomy in the subintimal space following successful CTO coronary guidewire crossing has been previously described as a possible adjunctive therapy for balloon-uncrossable CTO lesions (1). In our case, this technique allowed CTO recanalization without immediate complication. At 3-month follow-up, delayed covered coronary wall rupture was demonstrated by coronary angiogram. Percutaneous treatment was achieved by implantation of newer-generation thin-strut covered stents.
Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
CA demonstrating a severe stenosis of the proximal intermediate artery and a CTO of the LAD.
The CTO was crossed using antegrade dissection and reentry technique but was uncrossable with a 1.0-mm low-profile CTO balloon.
CA demonstrating intensive subintimal plaque modification by the means of rotational atherectomy using a 1.25-mm burr.
CA showing good final angiographic result after the implantation of 2 zotarolimus-eluting stents to proximal and mid-LAD.
Three-month control CA demonstrating 2 large areas of contrast extravasation at the site of previously implanted stents on proximal and mid-LAD suggesting delayed covered coronary artery wall rupture.
CA demonstrating the implantation of 2 thin-strut covered stents to the proximal and mid-LAD with immediate complete disappearance of the contrast extravasation.
Six-month control CA demonstrating patent covered stents and no residual contrast leakage.
Reference
- 1.Azzalini L., Vo M., Dens J., Agostoni P. Myths to debunk to improve management, referral, and outcomes in patients with chronic total occlusion of an epicardial coronary artery. Am J Cardiol. 2015;116:1774–1780. doi: 10.1016/j.amjcard.2015.08.050. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
CA demonstrating a severe stenosis of the proximal intermediate artery and a CTO of the LAD.
The CTO was crossed using antegrade dissection and reentry technique but was uncrossable with a 1.0-mm low-profile CTO balloon.
CA demonstrating intensive subintimal plaque modification by the means of rotational atherectomy using a 1.25-mm burr.
CA showing good final angiographic result after the implantation of 2 zotarolimus-eluting stents to proximal and mid-LAD.
Three-month control CA demonstrating 2 large areas of contrast extravasation at the site of previously implanted stents on proximal and mid-LAD suggesting delayed covered coronary artery wall rupture.
CA demonstrating the implantation of 2 thin-strut covered stents to the proximal and mid-LAD with immediate complete disappearance of the contrast extravasation.
Six-month control CA demonstrating patent covered stents and no residual contrast leakage.