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Multi-Vessel Disease: LAD and Ramus

Physician(s)

Ramesh Daggubati, MD

Patient History

A 60-year-old African American male smoker was referred for a percutaneous coronary intervention (PCI) of severely calcified lesions in the mid left anterior descending (mLAD) and ramus intermedius coronary arteries. The patient was deemed to be high risk for bypass surgery due to COPD, low ejection fraction (30%) and current dialysis treatment, but was an appropriate candidate for atherectomy. Medical history included hypertension, multi-vessel coronary artery disease, and decompensated heart failure requiring multiple hospital admissions.

The patient presented with unstable angina at an outlying hospital where a cardiac catheterization revealed 80% stenosed mLAD and 70% stenosed ostial ramus intermedius lesions. Severe calcification was noted in both via angiography.

The patient’s Syntax score was 15.

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Treatment Summary

Right common femoral arterial access was obtained, and an Impella 2.5 Ventricular Assist System [AbioMed, Inc.] was inserted and provided cardiac output support throughout the procedure. For the PCI, arterial access was achieved through the right radial artery and a 6 Fr Extra Back-Up (EBU) guide catheter was used to engage the left main artery.

The Diamondback 360® Coronary Orbital Atherectomy System (OAS) 1.25 mm Classic Crown was inserted and advanced to the LAD lesions. Two separate LAD lesions were treated, a proximal and distal segment. The proximal segment was treated with four OAS runs on low speed (80,000 rpm) while the distal segment was treated with three OAS runs on low speed, and the Diamondback crown was then removed. Post orbital atherectomy, the lesions were further treated with a 2.5 mm x 12 mm balloon dilatation catheter, which presented with no waisting. Balloon angioplasty was followed by successful delivery and deployment of a 3.0 mm x 38 mm drug-eluting coronary stent at 12 atm to the mLAD. Additional balloon inflations at 14 atm, were performed, and the stent expanded with ease. A second drug eluting stent – 3.0 mm x 12 mm – was delivered proximal to the initial stent, with slight overlap, deployed at 14 atm to cover the entire lesion and treated area.

Treatment of the lesion in the ostial ramus intermedius coronary artery followed. A frontline guide wire was delivered into the distal vessel, and a 1.2 mm x 6 mm over-the-wire balloon was inserted. An exchange to the ViperWire Advance® followed. OAS treatment consisted of four runs on low speed. Post OAS, a frontline guide wire was re-inserted into the LAD for an angiographic marker to ensure optimal coverage of the ostium of the ramus intermedius. A 3.0 mm x 8 mm drug-eluting stent was inserted and deployed at 14 atm. No complications were noted during the procedure. Total procedure time was 2 hours, 1 minute including Impella implant and explant. Total contrast use was 140 ml and total fluoroscopy time was 37.3 minutes.

In summary, successful orbital atherectomy, PTCA and stenting of the mLAD and ramus intermedius was performed in this complex procedure.

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Key Takeaways

  • Orbital Atherectomy was safely performed in a complex patient.
  • PCI optimization was achieved using Orbital Atherectomy to help maximize stent expansion and apposition.
  • The quick and easy setup of the Orbital Atherectomy system helped to facilitate a complex multi-vessel PCI.
  • Dr. Daggubati utilizes a trans-radial approach for orbital atherectomy (OA), PTCA and stenting, when appropriate, due to low access site complications and patient satisfaction.
  • The Diamondback 360 Classic Crown allows for a trans-radial approach to treat 2 mm-4 mm* coronary vessels with a single 1.25 mm crown.

Results may vary.

*Based on minimum reference vessel diameter as determined by orbit testing in a carbon block model system.

Pre & Post Procedure Images

Pre-Procedure Ramus
Post-Procedure Ramus
Pre-Procedure LAD
Post-Procedure LAD

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