The Use of Imaging to Guide Treatment Decisions with Coronary Orbital Atherectomy – Case 1 of 2
Dr. Brock Cookman describes this real-world case to demonstrate the importance of imaging to determine strategy and treatment in complex scenarios and how the unique dual-action mechanism of action (MOA) of the Diamondback 360® Coronary Orbital Atherectomy System sands superficial and fractures deep calcium.
A 77-year-old male patient presented with chest pain and associated radiation to the left arm with exertion concerning for unstable angina. He had a stress test concerning for inferior ischemia and underwent cardiac catheterization. He underwent PCI of the RCA as the culprit vessel for his unstable angina; however, he was found to have significant calcified stenosis of the LAD/Diagonal.
Physiologic assessment in the form of RFR was hemodynamically significant in the LAD distribution at 0.87. RFR of the diagonal was not hemodynamically significant. He was scheduled for staged intervention of the LAD with intravascular imaging and potential atherectomy. Intravascular imaging of the LAD showed a heavily calcified stenosis; the arc of calcium was greater than 180º, thickness greater than 0.5 mm and a length of calcium greater than 5 mm.
Based on the OCT-based calcium scoring system, this patient would score 4 out of 4 points. Without appropriate calcium modification, there is significant concern for stent under expansion and ultimately poor long-term outcomes.
Orbital atherectomy was performed of the LAD with appropriate lesion modification. There was evidence of calcium modification/fracturing on the post-atherectomy images. Post-OCT guided PCI showed greater than 90% stent expansion without evidence of proximal or distal edge dissection.
Due to plaque shifting into the diagonal, PCI was performed with a stent into the diagonal as well with final kissing balloon inflations.
- Coronary calcification is an increasing problem in patients undergoing Percutaneous Coronary Intervention (PCI) procedures.
- The Diamondback 360® Coronary Orbital Atherectomy System has a unique dual-action mechanism of action (MOA) that sands superficial and fractures deep calcium, which has been demonstrated through imaging.
- Based on OCT-based calcium scoring, without atherectomy, this patient would be at very high risk for stent under expansion, which ultimately leads to poor long-term outcomes and increased risk for target vessel revascularization.
- By utilizing coronary orbital atherectomy, there was appropriate evidence of calcium modification and appropriate stent expansion, which will lead to better long-term results.
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