SS–04 Dual Plaque Modification Strategy in High-Risk Complex PCI

Abstract

Introduction and Aim: The success of percutaneous interventions in fragile patients with severely calcified and multivessel coronaryartery disease depends on optimized lesion preparation. When the calcific burden is extremely high, a singledevice may not be sufficient. In this case report, we aim to present a complex percutaneous coronaryintervention (PCI) procedure successfully managed by combining two different advanced plaquemodification methods—rotablation and a cutting balloon—in the same session in a patient with activemalignancy and end-stage renal failure who refused surgery.

Case Report: A 79-year-old female patient presented to the emergency department with shortness of breath. Her medicalhistory included diabetes mellitus, hypertension, chronic kidney disease (stage 3/7 hemodialysis), and ahistory of breast cancer (right mastectomy in 2024). The patient, whose ECG showed normal sinus rhythmwith no ST-segment elevation, was admitted with a diagnosis of non-ST-elevation acute coronary syndrome(NSTE-AKS). Transthoracic echocardiography showed normal left ventricular (LV) dimensions and systolic functions (ejection fraction of 55–60%) along with normal right-sided structures. While degenerativechanges were observed in the valves, a gradient of 15/26 mmHg on the basis of calcific aortic degeneration,mild aortic regurgitation, mild-to-moderate mitral regurgitation, and mild tricuspid regurgitation weredetected. Thorax CT revealed bilateral pleural effusion and cardiomegaly. Coronary angiography (CAG)revealed a severely calcified and thrombotic long lesion causing 50–60% stenosis in the left main coronaryartery (LMCA), 60–70% stenosis in the left anterior descending (LAD) artery, and 80–90% stenosis in the circumflex (CX) artery. Coronary artery bypass grafting (CABG) was recommended by the Heart Team(Consensus); however, the patient and her relatives declined the surgical risk and provided informed refusalfor CABG. Consequently, a high-risk complex PCI strategy was decided for the patient.To overcome the heavy calcific lesions, a dual plaque modification strategy was planned. First, rotationalatherectomy (rotablation) was performed on the heavy calcific lesion in the LAD using a 2.0 mm burr. Following atherectomy, non-compliant (NC) balloon dilatations were performed, a 2.5x38 mm drug-elutingstent (DES) was implanted distally and a 3.0x28 mm DES proximally, and optimal luminal expansion was achieved by post-dilatations with intra-stent NC balloons. Subsequently, the procedure moved to the CXlesion; predilatation was performed on this lesion sequentially using 1.25, 1.5, 2.0, and 2.5 mm chronic totalocclusion (CTO) balloons, followed by 2.5 and 3.0 mm NC balloons. To complete the calcific lesionmodification, the second method—the cutting balloon strategy—was initiated. Dilatation was performedusing a 4.0x15 mm cutting balloon. Following successful plaque modification, a 4.0x38 mm DES wassuccessfully implanted in the CX artery, and high-pressure dilatation was performed with a 4.5 mm intrastentNC balloon. Complete luminal patency (TIMI-3 flow) was achieved at the end of the procedure, and thepatient was discharged stably with a plan for medical follow-up.

Conclusion: In patients with heavily calcified multivessel disease, the sequential or combined use of plaque modification methods with different mechanisms, such as rotablation and cutting balloons, is life-saving for stent success and expansion.