Trans-coronary Pacing via Rota Wire Prevents Bradycardia During Rotational Atherectomy: A Case Report

Back ground Rotational atherectomy (RA) is used for plaque modification in patients with heavily calcified coronary lesions. RA can induce significant bradycardia or atrioventricular block requiring for temporary pacemaker insertion. In this report, we present a case of trans-coronary pacing via a Rota wire to prevent bradycardia during RA in the proximal right coronary artery (RCA). Case summary A 72-year-old woman with a one month history of worsening effort angina was admitted to our hospital. Computed tomography coronary angiography disclosed significant coronary stenosis with severe calcification in proximal RCA. Coronary angiography revealed significant coronary stenosis with severe calcification in the proximal RCA. Subsequently, percutaneous coronary artery intervention was performed under the guidance of intravascular ultrasound(IVUS). The pull-back IVUS showed a circumferential calcified lesion in the proximal RCA, that was treated using RA, which induced significant bradycardia requiring temporary pacemaker insertion. Immediately, trans-coronary pacing was provided via a Rota wire placed in the far distal RCA; this was used for back-up pacing during RA. RA was completed by safely modifying the calcified lesion. After successful debulking of the calcified lesion, we dilated with a balloon, and a drug-eluting stent was implanted at the proximal RCA. Final IVUS and angiography showed good stent apposition and expansion. we did not observe any serious intraprocedural complications. Discussion RA is used for plaque modification in patients with heavily calcified coronary lesions. RA can induce significant bradycardia or atrioventricular block requiring for temporary pacemaker insertion via the transvenous route. This method could be an effective method to prevent bradycardia during RA.

662 Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

Aims Percutaneous coronary interventions (PCI) in calcified coronary artery lesions are associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using calcium modifying techniques such as Rotational Atherectomy (RA) or Intravascular Lithotripsy (IVL) has been advocated. Studies comparing these technologies are lacking. We aimed to compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either RA or IVL. Methods and results Patients undergoing either RA- or IVL-assisted PCI from two European centres were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post-PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥0.90. From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0.65 ± 0.13 RA and 0.67 ± 0.11 IVL). After PCI, in-stent pressure gradients was significantly lower in the IVL group (0.032 ± 0.026 vs. 0.043 ± 0.026 in the RA group, P = 0.024). The proportion of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; P = 0.669). Conclusions Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL. 662 FigureIn stent gradients after RA and IVL. (A) Box plot depicting the distribution of the in-stent pressure gradient vFFRgrad between the two groups. (B) Cumulative frequency distribution curves demonstrating lower vFFRgrad after intravascular lithotripsy compared to rotational atherectomy. RA, rotational atherectomy; IVL, intravascular lithotripsy; vFFRgrad, in-stent pressure gradient.

Nora’s lesion of the distal ulna: a case report

Nora’s lesion, also known as bizarre parosteal osteochondromatous proliferation (BPOP), is a very rare benign lesion with few published cases. BPOP is more common in adults during the second to third decades of life, and usually occurs on the hands and feet. Radiologically, it appears as a calcified mass attached to the bone cortex that grows rapidly and that recurs easily following resection. Aggressive features on imaging and confusing histopathological findings usually result in misdiagnosis or mistreatment. Herein, we present a case of a rare bony tumour involving the distal ulna presenting as a painless growing mass. An excisional biopsy with clear margins was performed without disturbing the ulnar nerve and arteries. There was no recurrent mass or calcified lesion 1 year after surgery. Based on its rarity and difficult diagnosis, BPOP should be considered in the differential diagnosis of a painless mass in the distal ulnar region. Careful follow-up after surgery is essential, even without lesion recurrence.

Abnormal shadow on chest radiograph: a supra – or infradiaphragmatic finding?

Incidental findings on chest X-ray of oncological patients need further evaluation in contrast-enhanced computed tomography (CT). We report two cases of abnormal shadows, detected on radiograph, in patients with breast cancer: the first one projected under the left hemidiaphragm and the second one obscuring the right hemidiaphragm. Both patients were asymptomatic, subjected to a surgery and to a CT. The first scan revealed a 15 mm diameter nodule in left lung with smooth margins and central calcifications. Whereas, the second exam showed a subcapsular, ring, calcified lesion in the liver. In both cases, CT was essential for staging and therapeutic choice.

The Effect of Aggressive Wire Recanalization in Calcified Atheroma and Dilatation (ARCADIA) Technique in Eccentric Calcified Lesion of No-stenting Zone

Purpose: The endovascular approach for eccentric calcified lesions of the no-stenting zone is challenging. This study aimed to investigate the effect of a novel technique for these lesions. Methods: We performed EVT for severe and eccentric calcified lesions using the technique, which is presented previously and named aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA). In brief, a guidewire is passed to the residual lumen firstly. Next, another guidewire is advanced into and cross through the calcified plaque and returned to the distal original lumen with intravascular ultrasound (IVUS) guided. The calcified plaque is dilated by using a scoring-balloon or non-compliant balloon. Results: Consecutive 14 peripheral artery disease patients with isolated and eccentric calcification in a no-stenting zone were treated using ARCADIA technique between January 2018 and March 2020. In IVUS data, lumen cross-section area was significantly increased from 5.2 ± 2.0 mm2 to 18.1 ± 6.9 mm2 (p < 0.01), lumen area was expanded roundly evaluating as symmetry index from 0.45 ± 0.09 to 0.81 ± 0.12 (p < 0.01). There were no distal embolization and perforation after ARCADIA technique. One-year target lesion revascularization occurred in only 2 cases. The primary patency of 1 year was 85.7%. Conclusion: ARCADIA technique is safe and appropriate, and can be 1 option to treat for eccentric calcified lesions of the no-stenting zone as an optimal wire crossing method.

The rotational atherectomy with a guide extension catheter for calcified and tortuous lesions in left anterior descending artery: a case report

Background The interventional treatment of calcified lesions with severe tortuosity in the left anterior descending artery (LAD) was challenging and the report of rotational atherectomy with mother-and-child technique has been scarce. Case presentation An 84-year-old woman was hospitalized for non-ST-segment acute coronary syndrome. Coronary angiography revealed a calcified nodule in the LAD. During rotational atherectomy of the calcified and tortuous lesion in the proximal LAD, eccentric cutting due to wire bias nearly caused perforation. The burr seemed to protrude from the contrast media during angiography. Intravascular ultrasound imaging revealed that extremely eccentric ablation almost reached the adventitia. We successfully ablated the distal calcified nodule by preventing proximal overcutting of the tortuous lesion with support from a guide extension catheter, i.e., the mother-and-child technique, followed by the deployment of the drug-eluting stent. The patient was discharged without chest symptoms and no symptom recurred during 12-month follow-up. Conclusion This case demonstrated that safe ablation of a calcified nodule located distal to a tortuous and calcified lesion in the proximal LAD with the mother-and-child technique.

Finite element analysis of cutting balloon expansion in a calcified artery model of circular angle 180°: Effects of balloon-to-diameter ratio and number of blades facing calcification on potential calcification fracturing and perforation reduction

Calcified artery lesions cause stent under-expansion and increase the risk of in-stent restenosis and stent thrombosis. Cutting balloons facilitate the fracturing of calcification prior to stent implantation, although vessel dissection and perforation are potential issues. In clinical practice, calcifications having maximum calcium angles ≤ 180° are rarely fractured during conventional balloon angioplasty. We hypothesize that the lesion/device diameter ratio and the number of blades facing a non-circular calcified lesion may be crucial for fracturing the calcification while avoiding vessel injury. The geometries of the cutting balloons were constructed and their finite-element models were generated by folding and wrapping the balloon model. Numerical simulations were performed for balloons with five different diameters and two types of blade directions in a 180° calcification model. The calcification expansion ability was distinctly higher when two blades faced the calcification than when one blade did. Moreover, when two blades faced the calcification model, larger maximum principal stresses were generated in the calcification even when using undersized balloons with diameters reduced by 0.25 or 0.5 mm from the reference diameter, when compared with the case where one blade faced the calcified model and a balloon of diameter equal to the reference diameter was used. When two blades faced the calcification, smaller stresses were generated in the artery adjacent to the calcification; further, the maximum stress generated in the artery model adjacent to the calcification under the rated pressure of 12 atm when employing undersized balloons was smaller than that when only one blade faced the calcification and when lesion-identical balloon diameters were used under a nominal pressure of 6 atm. Our study suggested that undersized balloons of diameters 0.25 or 0.5 mm less than the reference diameter might be effective in not only expanding the calcified lesion but also reducing the risk of dissection.