Treatment of Calcified LAD

Overview

Dr. Jeff Chambers treated a calcified left anterior descending (LAD) using orbital atherectomy.

Patient History

A 65 year old male presented with chest pain and had a stress echo where he exercised for 06:56 seconds, electrocardiogram (EKG) revealed mild ST depression less than 1 mm at peak stress, but stress echo showed a moderate-sized area of apical ischemia.

Past medical history includes obesity, borderline diabetes, hyperlipidemia, sleep apnea, a history of retinal artery occlusion and history of present illness (HPI). Patient was referred for coronary angiography.

Treatment Summary

The patient’s baseline angiogram showed a severely calcified proximal LAD and the proximal LAD had a complex lesion just after the first diagonal, which was about 80 to 85 percent.

Then the LAD was calcified in the mid vessel, another complex lesion at the site of a second diagonal, which again appeared to be about 80 to 85 percent. The other artery showed moderate disease with 65 percent lesions in the circumflex and OM1 and moderate disease in the right coronary artery, with 60 percent distal right coronary artery, 50 percent PDA and 50 percent PLA. This was assessed with fractional flow reserve (FFR), it was decided to proceed with intervention.

Orbital atherectomy was selected to treat the lesions. A universal wire was preloaded in a micro catheter, then exchanged for the ViperWire Advance(R). The proximal LAD was treated with three passes on low speed and one on high speed.

A 2.5 x 12 NC balloon was expanded in the mid LAD to 10 atms yielding good balloon expansion. This was followed by a 3.0 x 12 balloon to 12 atms in the proximal LAD, also with good expansion. A 2.75 x 24 drug eluting stent was placed in the mid LAD across the second diagonal, deployed this at 12 atms. A 3.0 x 24 drug eluting stent was placed in the proximal LAD, overlapping with the mid LAD stent and extended almost back to the ostium, deployed at 12 atms.

The lesion was then post dilated with a 3.0 x 20 NC balloon in the proximal vessel and a 2.75 x 20 balloon in the mid LAD. Both were treated at 16 atms. Very good angiographic results confirmed the success of this procedure.

Key Takeaways

Given the severe calcium, stent expansion would not have been able to have been achieved without orbital atherectomy on this case.


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