Comprehensive Optical Coherence Tomography-Guided RotaTripsy for Massive Coronary Calcified Nodule: A Decision-Making Approach (JACC Case Reports October 2024)-Article: Comprehensive Optical Coherence Tomography-Guided RotaTripsy for Massive Coronary Calcified Nodule: A Decision-Making Approach

Article: Comprehensive Optical Coherence Tomography-Guided RotaTripsy for Massive Coronary Calcified Nodule: A Decision-Making Approach

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This case report describes the intricate process of managing a heavily calcified coronary nodule (CN) in an 81-year-old woman with extensive cardiovascular comorbidities, including hypertension, hyperlipidemia, diabetes, and a history of smoking. Despite optimal medical therapy, she struggled with worsening angina. Diagnostic tests revealed severe two-vessel disease with significant calcification and flow limitations.<br /><br />Key procedural steps included:<br />1. <strong>Initial Rotational Atherectomy (RA):</strong> A 1.5-mm burr was used to modify the calcified obstruction. Optical coherence tomography (OCT) showed multiple obstructive CNs and substantial adjacent calcified plaques.<br />2. <strong>Further Debulking:</strong> As the initial RA showed inadequate lesion modification, the burr was upsized to 2.0 mm.<br />3. <strong>Intravascular Lithotripsy (IVL):</strong> A 3.5-mm Shockwave balloon was used to achieve deep calcium fractures in the calcified nodules.<br />4. <strong>Final Stenting:</strong> A drug-eluting stent was successfully deployed, followed by adequate post-dilation, ensuring satisfactory stent expansion.<br /><br />The procedure emphasized the importance of comprehensive intravascular imaging for detailed assessment and treatment planning. Combining RA and IVL, termed "RotaTripsy," provided a synergistic approach for extensive calcified lesions. However, the method required careful handling to avoid complications like burr entrapment or inadequate lesion modification.<br /><br />Potential pitfalls included:<br />- <strong>Burr Entrapment:</strong> Mitigated by starting with a smaller burr and using a slow pecking motion.<br />- <strong>Inadequate Lesion Modification:</strong> Addressed by progressively upsizing the burr.<br />- <strong>Failure to Achieve Calcium Fractures:</strong> Managed with adjunctive IVL.<br /><br />The patient was discharged without adverse events and remained symptom-free at the three-month follow-up. The report underscores the significance of a tailored approach using advanced intravascular imaging and the strategic integration of cutting-edge interventional techniques to optimize outcomes for complex calcified coronary lesions.

Keywords

calcified coronary nodule

rotational atherectomy

intravascular lithotripsy

drug-eluting stent

optical coherence tomography

cardiovascular comorbidities

severe two-vessel disease

RotaTripsy

calcium fractures

interventional techniques