Case 157: Manual of PCI: 10 min Rota + OPN

A patient with prior PCI of the LAD presented with NSTEMI. Coronary angiography showed multivessel coronary artery disease with an under-expanded proximal LAD stent, distal left main disease, and proximal/mid RCA lesions. He was turned down for CABG and referred for PCI. The RCA and left main were successfully stented, but the LAD lesion remained undilatable despite intravascular lithotripsy (3.0 and 3.5 mm balloons for a total of 160 pulses), high pressure balloon inflation, Angiosculpt, SIS-OPN at 50 atm, orbital atherectomy at low and high-speed, and laser with contrast. After 9 min 52 seconds of rotablation with a 2.0 mm burr up to 225,000 rpm the lesion was crossed by the burr. Although expansion was better it was still suboptimal but using a 3.5 mm SIS-OPN balloon good stent expansion was achieved.

[@drmz2007]

Excellent demonstration of all the calcium modification techniques. I have discussed one such case with my senior in which he used a cto wire to manipulate subintimal space behind the stent and then post dilatation done by opn balloon.

[@matheuscsmed]

Thank you, Matheus Silva

[@odraccir80]

Very interesting case. After stent ablation it is not recommended to place another stent?

[@shangz0216]

Thanks for the excellent case presentation.

[@hifa63]

Very impressive case . Many thanks

[@jwilson3985]

Awesome. Did you consider 4.0 x 40 DCB of LAD after putting in all that work?

[@wilzboyz]

Great case.

[@Альбертини-51]

Great case! Thanks! My finally option OPN NC. I wait roto and ivus....

[@BuddDwyer]

Holy moly!

[@AbdullahGuven-ec9bn]

thanks for this case after stent ablation using rota can you show us ivus images whether stent deformation

[@SoonKyu515]

I'm curious that wouldn't it be likely to cause stent fracture when you use rotablation within an underexpaneded stent if there's not much ISR?

[@viktorsasi7453]

Hard to understand why laser did not work. Above 10000 trains +OPN NC should have done it. With the optional rotablation and OPN solved the problem. I think laser was a big contribution though.

[@sachinpatil-bq4ge]

Just to add. Exactly like u r case. Prior attempt. OPN didn’t work, IVL didn’t work. Second attempt ROTA did the job and after well fried and heated lesion OPN worked.

[@nelsonhenriquefantinfundao6038]

Excellent case. I am in doubt if after using all these devices to expand the previously implanted stent, did you consider placing a new stent or using a drug-eluting balloon afterwards?

[@manosbrilakis]

Great point: coronary DCBs are not approved yet in the US. We considered placing another DES (which is done after most stent-ablations) but decided to not do so, given good final result.

[@balbirsingh-wf5wx]

Would like to know cost of the procedure?? Well done case

[@sachinpatil-bq4ge]

Congratulations for a great case. I did stent ablation for a very similar case. 1.75 burr couldn’t pass after 10 min. Then taken 1.5 crossed at 4.25 minutes but 2 times entrapment, was lucky get out of it. Finally OPN helped. But. I did put the stent. Any reason why u didn’t put the stent. How safe OPN at 50. I usually don’t go above 40. Had ruptures 5-6 in the past. Fortunately OPN rupture is much safer than routine NC. My personal opinion. U r comments please.

[@manosbrilakis]

Great points - my OPN experience is quite limited as we only recently got access to the device. Agree that a stent might help

[@guozhuchen5511]

So tough case! Thank you for your share. Use all the methods to treat stent underexpansion, including SIS, IVL, ELCA, OA, Rota, nice. I am interesting in that did you do the polish after the Burr cross the lesion because video only shown Burr cross the lesion? Second is the Burr will damage the LM-proximal stent during Rota or not? Thanks.

[@manosbrilakis]

Great points - we did not bring the burr back to the fresh stent. We did a few polishing runs after the burr crossed the lesion.

[@guozhuchen5511]

@@manosbrilakis Thank you for your reply! Learn a lot of knowledge from your videos! 😁

[@mohammedaldumini]

👍

[@NikhilJha89]

What about 2 simultaneously inflated nc balloon

[@manosbrilakis]

Thank you - we did not try this technique.