An application of RASER technique in the treatment of chronic total occlusion accompanied with stent fracture in right coronary artery: a case report
- 109 Downloads
The interventional treatment of chronic total occlusion (CTO) with stent fracture as well as severe calcification was extremely difficult and no effective technique has been reported.
A 50-year-old woman was hospitalized for angina, angiography revealed triple vessel disease, CTO accompanied with stent fracture in right coronary artery (RCA). Treatment using conventional coronary intervention was expected to be difficult. Therefore, we performed RASER technique, which was a combination of excimer laser coronary atherectomy (ELCA) with rotational atherectomy (RA), followed by the deployment of drug-eluting stents. Intravascular ultrasound (IVUS) revealed well attachment of the stents, the patient was discharged 3 days after the procedure and no recurrent chest discomfort was reported in a follow-up time of 10 months.
This case report provided a first report of RASER technique in the treatment of CTO with stent fracture and severe calcification.
KeywordsExcimer laser coronary atherectomy Rotational atherectomy Chronic total occlusions RASER technique
Chronic total occlusion
Drug eluting stent
Excimer laser coronary atherectomy
Second obtuse marginal
Percutaneous coronary intervention
Right coronary artery
Although drug-eluting stent based intervention has become the most widely used treatment for coronary heart disease, a high incidence of in-stent restenosis after coronary stent implantation remains an important challenge . Previous studies demonstrated that rotational atherectomy (RA) is safe and effective to treat stent restenosis [2, 3]. Meanwhile, excimer laser coronary atherectomy (ELCA) has a long history of adjunctive therapy that can be applied to treat in-stent restenosis (ISR) . However, in particular case of complicated CTO after ISR, microcatheter and Rota Wire could not pass the lesion, makes the operation difficult. The RASER technique combines ELCA with RA, since ELCA could provide an upstream channel to permit microcatheter and Rota Wire passage, while RA could fully debulk the lesion . Unfortunately, there is no report regarding combination of ELCA and RA in CTO accompanied with stent fracture. In the current report, we described a novel application of RASER technique to successfully treat in-stent occlusion accompanied with stent fracture in RCA.
Discussion and conclusion
In this case, we successfully performed RASER technique using ELCA for ISR ablation combined with RA for rotational ablation in a patient with CTO in RCA accompanied with stent fracture. The RASER technique achieved excellent angiographic and IVUS result, the patient recovered well after the procedure and was discharged 3 days later.
ELCA is a long-established adjunctive therapy that can be applied during complicated PCI. The indications of ELCA during PCI include thrombus, non-crossable or non-expandable lesions, chronic total occlusions, in-stent restenosis and stent under-expansion . The key advantage of ELCA over alternative atherectomy interventions is delivery on a standard 0.014-in. guidewire. The major limitation of ELCA is incompetency to ablate heavy calcification. In our case, CTO in RCA accompanied with stent fracture. Microcatheter could not pass the occlusion, indicating fibro-calcific nature of the lesion, which makes balloon dialation and rota ablation impossible. ELCA successfully created a channel after guidewire traversed the CTO lesion, which facilitated the passage of microcatheter and subsequent exchange of Rota Wire with guidewire. As the lesion was severely calcific, rotational atherectomy was necessary to fully debulk the lesion.
It was reported that longitudinal stent ablation by RA with a 1.75-mm burr was effective in treating under-expanded stent in CTO lesion with severe calcification . However, inability of Rota Wire to pass the lesion was a major problem. In addition, ELCA has been recognized as an alternative to treat ISR , but severe calcific lesion frequently led to unsatisfactory result treating with ELCA. Therefore, RASER technique, a combination of ELCA and RA was the optimal choice for CTO lesion with severe calcification. However, the application of RASER in CTO with stent fracture as well as severe calcification has not been reported before, our case received a satisfactory result.
The ELCA catheters can be delivered with a standard 0.014″ guidewire and 0.9 mm, 1.4 mm, 1.7 mm, and 2.0 mm catheters are available. Studies showed that 0.9 and 1.4 mm catheters are more frequently used in CTO cases . In the present case, we performed a 1.4-mm burr excimer laser catheter with a pulse rate of 40 Hz and energy output of 45 mJ/mm2 to ablate occlusion for 3 times. Alternatively, a 0.9-mm ELCA catheter is suggested when the lesion is severely occluded accompanied with calcification .
In summary, this is the first report of successful application of RASER technology in patients with CTO accompanied with severe calcification and stent fracture. This case report may extend ELCA indications and provide a novel approach to complicated PCI. Eventually, with the increase of cases and the accumulation of experience, patients who were unable to undergo conventional PCI will benefit.
YX, WW, GM, OZ, JZ, YG, YZ, CR performed PCI, YX, BZ and PZ wrote the paper. All authors have read and approved the manuscript.
Yajun Xue received funding from State Key Laboratory of Low-Dimensional Quantum Physics, Tsinghua University (KF201608). Yajun Xue performed PCI and wrote the paper, grant KF201608 supported collection, analysis, interpretation of data. Boda Zhou received funding from National Natural Science Foundation of China (81970299). Boda Zhou wrote the paper, grant 81970299 supported collection, analysis, interpretation of data.
Ethics approval and consent to participate
The study was approved by the ethics committee of Beijing Tsinghua Changgung Hospital, the patient gave writen consent to participate in the study.
Consent for publication
Writen informed consent for publication was obtained from the patient.
The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.