Chapters Transcript Video The Rock: Coronary Calcium Restricting Stent Expansion Back to Symposium Ronald S. McKechnie, M.D., describes how to approach cases considered for lithotripsy with enhanced balloon dilation for calcified coronary lesions. My title is the rock. That's really what we're dealing with. Some rocks can be changed into diamonds. Some like the Rock of Gibraltar stay there, some like Alcatraz stays there. And sometimes you need the rock to make things happen here, Dwayne Johnson. But this is what we're talking about coronary rocks. This is a nice um picture on a ct scan that really shows the heavy calcification. That's not necessarily appreciate it on an joe. And we used to sometimes in our treatment planning certainly with ceos but remember that other imaging modalities than just invasive help help us plan this procedure. So I'm going to go through just a single case on laser trip. See, so this is an 81 year old retired position who's had multiple stents in the past. Um He had presented our uh sister hospital with unstable angina. He had instant recent notice of an L. I. D. When looking back to when it was originally placed, was actually under expanded at that time. And the season interventional ists there performed angioplasty with really persistent under expansion of that stent and inability to get a reasonable loom in. Nonetheless, the patient was sent home on medical management. Uh and the concept of referring him for single vessel bypass Gisella de was considered, he represented after that initial event with another episode of West angina despite nitrates calcium channel blockers. And it's on chronic Plavix. So again, he's had multiple stents In the 90s and early or mid 2000s Gisella and cirque. It had stents been treated by a partner with heart failure. But ultimately at that facility did not undergo repeat angio, but was sent over for consideration of a thyroidectomy versus cabbage. So in june, this is before we brought him to the lab. This shows the heavy calcification. He's got laid stents in the proximal and mid vessel and add a bifurcation of two separate diocese, has severe instant restenosis. And while looking at it, you'll appreciate that there is under expansion of this uh sense. So this shows a partner performed high pressure balloon angioplasty and you'll appreciate that there is under expansion of the balloon. This is a 3.0 millimeter balloon noncompliant at 30 atmospheres. So it was not going to give way but he was left with. But this is another view of that, showing that there's calcification clearly impeding its expansion And this is how he has left on the preceding procedure. Again, maybe the Lumen has rather than the 90% stenosis, 85% stenosis but had reasonable flow downstream. So, when he came to that hospital, he's transferred for consideration of laser for better expansion of the instant restenosis and the extrinsic calcification and compression. This is just a description of what was used through the procedure and I'll go through the angio. But it was a combination of laser ibis cutting balloon, high pressure balloons ultimately shockwave, which is with a trip see, high pressure balloon and then subsequent scenting. So this is his repeat pictures. Again, not much different than the original ones from a month preceding this. This shows really we had to be pretty aggressive with bringing our laser into that area within the as you see there's a run of the laser coming both forward and backwards. We used escalating levels of laser in this stent, both in the proximal and that mid vessel We have 60, 60, 80 80 With saline followed by uh 60 60 with half contrast and half sailing, which helps penetrate the calcification. And despite this laser runs multiple times through uh still was unable to yield and so finally were able to deliver. We thought that since the laser wasn't expanding the scent, um We tried another mode with literacy and this shows a three oh balloon. And again, we needed multiple runs of the balloon around this spot with final X expansion, there's a little bit of a bend but it's much better expanded than those original balloons. And uh the show's again, there's some mild smoothing effect of the of the stent. But we finally got expansion and it just shows the differential, both laser and sometimes using an alternative we we went into the procedure understanding we might use it, but it was through discussions with other partners to say if it doesn't work, this is another option. So this shows what we used again, laser Four passes with 60 60 80 85. This again trying to document the size of the vessel to match it with the little trip see another run of laser, Uh, an attempt at a noncompliant balloon cutting balloon and then the shockwave with non compliant balloon up to 30 atmospheres. So it was two separate overlapping sense on that with the office after the procedure to ensure that we have the extent expansion. Published Created by Related Presenters Ronald McKechnie, M.D. Sentara Cardiology Specialists View full profile
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