The Impact of Atherectomy in Patients Undergoing Complex PCI

A 73-year-old male patient was referred for urgent myocardial revascularization from an outside hospital due to cardiac arrest presenting with polymorphic ventricular tachycardia. His medical history was notable for non-insulin-dependent diabetes mellitus, hypertension, and dyslipidemia. He had recently undergone esophagectomy due to esophageal neoplasm, and a newly diagnosed exophytic right renal mass was under investigation. After esophagectomy, he suffered a major depressive episode and appeared deconditioned and not adequately nourished, having lost 65 lbs in under 4 months. Medical history was also significant for coronary artery disease, with previous percutaneous coronary intervention (PCI) with balloon angioplasty of the proximal left anterior descending artery (LAD) and subsequent PCI on the mid right coronary artery (RCA) in 2012.

Diagnostic coronary angiography revealed severely calcified proximal and mid LAD disease involving the bifurcation with the first diagonal branch (Medina 1-1-1) (Video 1), severely calcified circumflex artery with a focal lesion, and patent stent on the RCA (Figure 1). SYNTAX score was 30. Transthoracic echocardiogram showed normal left ventricle (LV) dimensions, an LV ejection fraction of 58% with normal segmental kinesis, normal right ventricle (RV) dimensions and function, no significant valve disease, and aortic root dilatation (5.0 cm). After discussion among the heart team, the patient was not considered suitable for surgery due to comorbidities and frailty. Percutaneous revascularization of the LAD-D1 was therefore attempted, leaving the circumflex artery to subsequent evaluation according to clinical course.

Video 1

Video 1

Figure 1: Baseline Coronary Angiography

Figure 1
(A) Cranial image showing severe calcified lesion of the LAD-D1 (Medina 1-1-1). (B) Caudal image showing calcified focal stenosis of the left circumplex. (C) Left anterior oblique and cranial view showing good result of previous stenting of the mid RCA, with aneurysmal dilatation.

As per standard local practice in the setting of complex PCI, the patient underwent right heart catheterization (RHC) before PCI. RHC documented low pulmonary artery (PA) oxygen saturation (54%) and cardiac index (1.99 l/min/m2). Other RHC parameters are listed in Table 1.

Table 1: RHC Pre-Procedure

Parameter Value
Right atrial pressure 5 mmHg
RV pressure 33/2 mmHg
PA pressure 30/7 (17) mmHg
Pulmonary capillary wedge pressure 10 mmHg
LV end-diastolic pressure 10 mmHg
PA oxygen saturation 54%
Aortic oxygen saturation 96%
Aortic pressure 140/84 (106) mmHg
Cardiac output 3.77 l/min
Cardiac index 1.99 l/min/m2
Cardiac power index 0.47 W/m2
PA pulsatility index 4.6

Which percutaneous revascularization strategy appears to be the most appropriate in this setting?

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