• Efficacy of Combination Atherectomy of Orbital Atherectomy System and Rotational Atherectomy for Severely Calcified Nodule

    A 73-year-old man who had stenosis with severe calcified lesion in the right coronary artery (RCA) underwent percutaneous coronary intervention. The lesion was observed with optical frequency domain imaging (OFDI) (Terumo Corporation, Tokyo, Japan) before the treatment. There was a calcified nodule protruding into the lumen of RCA ( Fig. 1 a ). At first, we performed orbital atherectomy with the Diamondback 360® coronary orbital atherectomy system (OAS) (Cardiovascular Systems, Inc.) for this lesion. We advanced the OAS through the lesion. Orbital atherectomy was performed three times at low revolution speed (80,000 rpm) while pulling back the crown to dig it into the calcified nodule. After that, OFDI showed that a new groove was created at the center of calcium nodule ( Fig. 1 b). As guide wire seems to move to safer position creating the opportunity for a more aggressive debulking, rotational atherectomy (RA) was performed using a 2.15 mm RotaPro (Boston Scientific Corporation) at 200,000 rpm. Subsequently, OFDI showed deeper groove formation inside the calcified nodule and the resultant luminal enlargement ( Fig. 1 c). After applying an additional high-pressure cutting balloon dilation (3.75/10 mm Wolverine with 20 atm, Boston Scientific, Natick, MA, USA), OFDI confirmed satisfactory luminal gain without the presence of major dissections ( Fig. 1 d), indicating coronary stent implantation was not required. The final angiogram showed a good result with a TIMI 3 Flow without any sign of complication. Each usefulness of OAS or RA for calcified lesion has already reported [  ]. If we want enough debulking effect for bulky calcified lesion with RA, we need to attach Rota bur to whole lesion. However, RA tends to ablate proximal part of lesion mainly and glance off the surface of distal part, especially in calcified nodule lesion because stiffness of device shaft and wire bias interfere with behavior of Rota bur to approach the distal part. When we considered where is the best guide wire position for aggressive RA, we thought that the center of vessel is safest and most effective guide wire position. OAS with low revolution speed was very useful to move guide wire into best position in this case. If we used high speed mode, wire position may move close to opposite wall because of aggressive orbital atherectomy and we may not use large-sized Rota bur. We could show that modification of guide wire position by OAS was highly effective for aggressive RA in this case.

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    Cardiovascular Revascularization Medicine Volume 28, July 2021, Pages 100-101


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