Introduction

Since the first balloon angioplasty by Andreas Gruntzig 40 years ago, interventional cardiology has witnessed the introduction of countless tools and techniques that have significantly contributed to broadening the application of percutaneous coronary interventions (PCI) in unprecedented anatomic settings. Heavily calcified, fibrotic coronary stenosis has traditionally represented a very challenging scenario for PCI, and a very common indication for surgical revascularisation. Thanks to dedicated cutting and scoring balloons and to atherectomy devices, the treatment of most fibrotic and heavily calcified stenoses has become feasible and safe.

Mechanism of Action

The principal mechanism for rotational atherectomy (RA) is differential cutting in which the diamond-tipped burr drills through rigid atherosclerotic plaque and calcium but spares the underlying elastic arterial structure. The resultant particulate matter is generally less than 10µm in diameter, which passes through the microcirculation and is picked up by the reticuloendothelial system. Case Report :    An Octogenarian  fragile  diabetic  lady presented  with ACS/NSTEMI/trop I positive with TIMI risk score 4. ECG revealed asymmetrical T wave inversion in lead V1 -V4 .Echocardiogrphy revealed RWMA in Apical and Apico-septal territory  with moderate LV dysfunction . In view of ongoing Angina patient taken for Coronary Angiography which revealed Calcified LAD (grade III) with Proximal to mid LAD involvement around 95 % (Type C ) fig 2 . LCX and RCA had intermediate disease. As Patient had tripple  vessel disease with moderate LV Dysfunction, so first option was CABG but patient was neither fit for surgery nor they were agreed to undergo  CABG .

Finally it was decided to debulk the lesion using State of Art Rotablation technique . Through 7 F EBU Guidecatheter , lesion was crossed with Runtrhough guidewire exchanged with rota wire and debulking done via 1.25 burr  (figure 3), finally pre dilatation by 2.5x15 mm   NC balloon and DES 2.5x38 mm  was deployed followed by post dilatation by 3.0x15 mm balloon resulting in TIMI 3 flow and  optimum stent expansion( figure 3 ).

Patient was discharged next day of procedure and doing well in follow up without any Angina and dyspnoea.

Our Centre has been one of the first centre in north east to use this State of Art Rotablation technique very frequently.

             FIG 1                                          FIG 2                                                                            FIG 3                                                                       FIG 4