By Richard R. Heuser, MD, and Khalid Naqi, MD
A 65-year-old army veteran presented with unstable angina. An outside angiogram revealed calcific ostial and proximal right coronary artery (RCA) stenoses.
The radial approach was utilized with an Ikari 1.5 guiding catheter. The lesion was crossed with a Whisper wire and utilizing the FineCross (Terumo) catheter, this was exchanged for the ViperWire (CSI). Following this, the CSI device debulked the proximal areas of stenosis. An AngioScore balloon performed further enlargement of the lumen. Finally, a 3.5 mm x 33 mm stent was placed (Xience). To optimize the ostial result, we placed the Flash ostial device (Cardinal Health). The final result revealed an appropriate apposition at the origin of the RCA vessel. By deploying a few millimeters more proximal, the Flash ostial device allowed us to get the optimal result at the origin of the vessel.
Ostial calcific stenosis always poses a challenge during atherectomy. The eccentric crown of the orbital atherectomy device may result in less downstream large embolic debris. Either way, we have found it to be effective in cases where adequate preparation of the vessel is necessary prior to stenting. The ostial lesions always are difficult to cross without adequate coverage of the origin. The Flash device may be one option in coronary and renal stenoses. We feel both of these technologies aided in a successful complication free treatment in this patient.
The addition of orbital atherectomy and a dedicated ostial balloon system may add value to the treatment of calcific lesions of the origin of the coronary arteries.
Images: Click the legend below to view the image.
Figure 1. RCA injection prior to crossing lesion.
Figure 2. Whisper wire across the stenoses.
Figure 6. Proximal balloon inflated.