• Rotational atherectomy of calcified Left Main and LAD lesions

    A 58-year old male, who presented with unstable angina and underwent PCI of acutely occluded RCA three weeks earlier, now presents for a staged PCI of the LM and LAD. Coronary angiography before PCI showed a 50-60% stenosis of the distal LM and 80-90% bifurcation lesion in the LAD with 30-50% stenosis in the D2 branch (Figure 1).  Moderate to severe calcification was detected by angiography in both, LM and LAD lesions.

     

    OCT pullback was performed in the LM and proximal LAD using a fast survey mode. The pullback detected circumferential calcification in the LAD lesion (Figure 2A, B, asterisks) with minimal lumen area (MLA) of 1.1 mm2 and a fibrocalcific plaque in the distal LM lesion, MLA = 4.1 mm2(Figure 2C). Calcified plaques were ablated by rotational atherectomy (RA) using 1.75 mm burr in the LM and 1.5 mm burr in the LAD for 40 sec at 150,000 rpm.

     

     

     

    Lesion modification with RA was followed by an implantation of two everolimus-eluting stents, 4/20 mm and 3.5/28 mm with a successful angiographic result (Figure 3).

     

    Postinterventional OCT imaging confirmed satisfactory expansion of both stents with minimal stent area (MSA) of 8.8 and 6.7 mm2 in the LM and LAD. A small dissection was detected at the distal edge of the LAD stent (Figure 4A, arrow). In addition, several malapposed struts  were observed around a post RA tissue dissection in the LAD stent (Figure 4B) and at the proximal edge of the LM stent (Figure 4C). The OCT findings were considered minor and not waranting an additional stent optimization.

     

     

     

     

  • ST-Elevation Myocardial Infarction arising from plaque erosion

    A 59-year-old male with no medical history arrived at emergency department due to sudden onset of chest pain radiating to back and shoulder. The ECG showed ST-elevation in leads V2-3 and an emergent coronary angiography revealed a total occlusion of the mid LAD. (Fig. 1, arrow).

     

    After wiring the LAD, an angiogram demonstrated a significant stenosis and filling defects (Fig. 2, arrow) suggesting thrombus with TIMI 3 flow.

    Figure 3 shows residual stenosis without obvious thrombus after thrombectomy and balloon angioplasty.

    OCT was performed to uncover the underlying mechanism of STEMI (dotted line in Fig. 3). The OCT pullback demonstrated an irregular luminal surface with residual white thrombus overlaying fibrous plaque (Fig. 4A1, 4A3).Minimal lumen area (MLA) was 1.3 mm2 (Fig. 4A2). There was no plaque rupture or a lipid rich plaque detected in the lesion by OCT, suggesting plaque erosion as an underlying mechanism of STEMI (Video 1).

     

     

     

    The obstructive lesion was treated by deploying a 3.0/28-mm drug eluting stent (Fig. 5).

    Post stent OCT (dotted line in Fig. 5) confirmed good stent expansion and apposition with a minimal stent area (MSA) of 4.94 mm2 (Fig. 6, Video 2). Small white thrombus and tissue protrusions were also demonstrated by OCT (Fig. 6C2, 6C3).