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Safety Assessment of Microcatheter-Protected Rotational Atherectomy with the Double Guiding Catheter Technique for Severely Calcified Left Main Bifurcation

Safety Assessment of Microcatheter-Protected Rotational Atherectomy with the Double Guiding... Hindawi Journal of Interventional Cardiology Volume 2022, Article ID 1399510, 8 pages https://doi.org/10.1155/2022/1399510 Research Article Safety Assessment of Microcatheter-Protected Rotational Atherectomy with the Double Guiding Catheter Technique for Severely Calcified Left Main Bifurcation Shijun Yang , Silai Dong, Yanzhao Zhou, Yumiao Wei, Ning Zhao, Chunhua Sun, and Xiang Cheng Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China Correspondence should be addressed to Xiang Cheng; nathancx@hust.edu.cn Received 10 April 2022; Revised 23 June 2022; Accepted 25 June 2022; Published 9 August 2022 Academic Editor: Joseph Dens Copyright © 2022 Shijun Yang et al. )is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Rotational atherectomy (RA) is a tool for calcium modification, but there is a risk of losing the side branch in left maincoronaryartery(LM)bifurcationlesions,resultingindisastrousconsequences.Microcatheter-protectedRA withthedouble guiding catheter (GC) technique for severely calcified LM bifurcations has been described previously, but its safety warrants further investigation. Methods. Various sizes of coronary calcification vascular simulators were utilized to model calcified LM bifurcation lesions for RA in in vitro. )e damage to the side branch protective microcatheters and guidewires was accessed after microcatheter-protected RA with the double GC technique. In clinical practice, microcatheter-protected RA with the double GC technique was carried out in two patients. Results. In vitro, none of the protective microcatheters or guidewires were completely fractured, although the majority of them were damaged to varying degrees. In clinical practice, we successfully carried out two cases of percutaneous coronary intervention for severely calcified LM bifurcation with microcatheter-protected RA using the double GC technique. Conclusion. RA of severely calcified LM bifurcation lesions may be successfully performed using microcatheter-protected RA with the double GC technique, potentially reducing the risk of side branch occlusion. Since majority of protective microcatheters or guidewires were damaged, there was still some risk, and it is recommended to use this technique only in highly selected patient population of severely calcified true (Medina 1, 1, 1) LM bifurcations. protected RA with the double guiding catheter (GC) tech- 1. Introduction nique, which has been reported in the past [4], raises Percutaneous coronary intervention (PCI) of lesions at left concerns about safety (especially the possibility of complete main (LM) bifurcations is consistently deemed a technical fracture of the protective microcatheter and guidewires). challengebecauseofthehighincidenceofcomplicationsand )us, we applied this technique in vitro to confirm its safety inferior clinical outcomes compared to those of non- and successfully performed the technique on two patients bifurcation lesions. Bifurcation coronary artery intervention with severely calcified LM bifurcations. may increase the risk of occlusion of a sidebranch due to the carinal shift while handling (via a balloon, atherectomy, or 2. Methods stent) the main branch [1]. Fujino et al. found that coronary bifurcation lesions with calcification predicted a higher risk 2.1. Materials Preparation. Microcatheters (130cm, Fine- of side branch occlusion [2]. Plaque modification with ro- cross, Terumo, Japan), 7-F ABU 3.5GC (APT Medical, tational atherectomy (RA) may reduce this risk, but the China),coronaryguidewire(AsahiSion,ASAHI,Japan),7-F associated side branch compromise still needs to be con- EBU 3.5GC (Medtronic, USA), the extracorporeal coronary sidered [3]. As an alternative solution, microcatheter- vascular simulator (Boston Scientific Corporation, USA), 2 Journal of Interventional Cardiology E G F H Figure 1: Extracorporeal coronary vascular simulator. (a) LM of the coronary vascular simulator. (b) LAD of the coronary vascular simulator. (c) 7-F ABU 3.5 GC (APT Medical, China). (d) 330 cm long RotaWire (Boston Scienti c Corporation, Massachusetts). (e) LCX of the coronary vascular simulator. (f) 7-F EBU 3.5 GC (Medtronic, USA). (g) Coronary microcatheter (Finecross, Terumo, Japan). (h) 180 cm long coronary guidewire (Asahi Sion, ASAHI, Japan). LM, left main coronary artery; LAD, left anterior descending coronary artery; GC, guiding catheter; LCX, left circum—ex coronary artery. and the 330 cm long RotaWire (Boston Scienti c Corpo- circum—ex artery(LCX) throughthesecondGC.  e RAof the ration, USA) were prepared. LM-LAD axis was performed with a 1.25 mm burr while protecting the LCX with the microcatheter (Figure 1, Sup- plementary Video 1). When RA of the LM-LCX axis was 2.2. In Vitro Experiment. An extracorporeal coronary vas- performed with a 1.25 mm burr, the microcatheter was placed cular simulator (Boston Scienti c Corporation, USA, Fig- in the LAD to protect the LAD in the same manner (Sup- ure 1) was used to simulate calci ed lesions.  ree sizes of plementaryVideo2). edamagetothesidebranchprotective coronary calci cation vascular simulators (Figure 2) were microcatheter and guidewire was evaluated after RA from the used for microcatheter-protected RA with the double GC dišerently sized calci ed lesion simulators. Observation and technique.  e steps are as follows: A 7-F ABU 3.5 GC (APT research indicators were as follows: number of damaged Medical, China) was used to engage the LM. A 180 cm long microcatheters, number of damaged guidewires, and number coronary guidewire (Asahi Sion, ASAHI, Japan) was inserted of completely fractured microcatheters or guidewires. into the left anterior descending artery (LAD) and was then replaced by a 330 cm long RotaWire through a coronary microcatheter in the anticipation of RA. Next, a 7-F EBU 2.3. Clinical Practice 3.5GC (Medtronic, USA) was used to engage the LM. A 180 cm long coronary guidewire with a 130 cm long micro- 2.3.1. Patient 1. A 75-year-old female with diabetes mellitus catheter (protective microcatheter) was placed into the left and hypertension presented with a 2-week history of chest Journal of Interventional Cardiology 3 5.0 mm 4.0 mm LM 1.25 mm 2.0 mm 1.25 mm LCX LAD 2.75 mm 3.0 mm (a) (b) 5.0 mm 4.0 mm LM 1.25 mm 2.25 mm 1.25 mm LCX LAD 2.75 mm 3.0 mm (c) (d) 5.0 mm 4.0 mm LM 1.25 mm 2.5 mm 1.25 mm LCX LAD 2.75 mm 3.0 mm (e) (f ) Figure 2: Structure diagram and real object of the coronary calci cation vascular simulator with dišerent diameters of distal LM. (a)-(b)  e diameters of distal LM are 2.0 mm. (c)-(d)  e diameters of distal LM are 2.25 mm. (e)-(f)  e diameters of distal LM are 2.5 mm. LM, left main coronary artery; LAD, left anterior descending coronary artery; LCX, left circum—ex coronary artery. tightness on exertion. Coronary angiography revealed se- microcatheter (Figure 3(c), Supplementary Video 4).  en, verely calci ed bifurcation stenosis of the LM, LAD, and the microcatheter was removed from the LAD and advanced LCX coronary arteries (Figure 3(a), Supplementary Video over the LCX guidewire into the LCX.  e RA of the LM- 3).  e patient refused to undergo cardiac surgery, and PCI LAD axis was performed with a 1.25 mm burr (Supple- was performed as an alternative treatment. mentary Video 5) and a 1.75 mm burr in the same manner A 7-F ABU 3.5GC (APT Medical, China) was used to (Figure 3(d)). After changing the guidewire, bifurcation engage the LM. Two 180 cm long coronary guidewires were intervention was performed using a double kissing crush inserted into the LAD and LCX. Intravascular ultrasound (DK crush) technique to treat the LM, LAD, and LCX (Figures 3(e) and 3(f)). (IVUS) was used to detect the LAD, LCX, and LM. IVUS showed calci cation throughout the whole course of the LM (Figure 3(b)). Using a 130 cm long coronary microcatheter 2.3.2. Patient 2. A 77-year-old male with diabetes mellitus (Finecross, Terumo, Japan), the coronary guidewire in the LCX was replaced with a 330 cm long RotaWire (Boston and hypertension presented with angina on exertion, which he had experienced for 4 months. Coronary angiography Scienti c Corporation, Massachusetts) in anticipation of RA.  en, a 7-F ABU 3.0 GC (APT Medical, China) was used revealed a severely calci ed bifurcation lesion at the end of the LM, with involvement of the ostia of both the LAD and to engage the LM.  e protective microcatheter and guidewire were placed in the dominant LAD through the LCX (Figure 4(a), Supplementary Video 6).  e patient strongly refused coronary artery bypass grafting and second GC.  e RA of the LM-LCX axis was performed with a 1.25 mm burr while protecting the LAD with the requested percutaneous coronary intervention. 4 Journal of Interventional Cardiology (a) (b) Rotational atherectomy device over LAD wire Microcatheter over LAD wire Rotational atherectomy device over LCX wire Microcatheter over LCX wire (c) (d) (e) (f ) Figure 3: Microcatheter-protected RA with the double GC in patient 1 (a) Left coronary angiography revealing severe calci ed LM bifurcation stenosis in LAO-caudal view. (b) IVUS showing severe calci cation in distal LM. (c) RA performed on the LM-LCX axis via the rst GC (7-F ABU 3.5 GC) with a 1.25 mm burr and the LAD protected by the microcatheter and guidewire through the second GC (7-F ABU 3.0 GC). (d) RA performed on the LM-LAD axis via the rst GC (7-F ABU 3.5 GC) with a 1.25 mm burr and the LCX protected by the microcatheter and guidewire through the second GC (7-F ABU 3.0 GC). (e) Final kissing balloon with noncompliant balloons to optimize the LM reconstruction. (f) Final postintervention coronary angiography in LAO-caudal view. RA, rotational atherectomy; GC, guiding catheter; LAO, left anterior oblique; IVUS, intravascular ultrasound; LM, left main coronary artery; LCX, left circum—ex coronary artery; LAD, left anterior descending coronary artery. A 7-F ABU 3.75GC (APT Medical, China) and a 7-F LAD with the microcatheter (Figure 4(c), Supplementary ABU 3.5GC (APT Medical, China) were used to engage the Video 7).  e microcatheter was removed from the LAD and LM. A 180 cm long coronary guidewire was passed into the advanced over the LCX guidewire into the LCX.  e RA of LAD and LCX through dišerent GCs. IVUS was used to the LM-LAD axis was performed with a 1.25 mm burr detect the LAD, LCX, and LM.  e IVUS probe could not (Supplementary Video 8) and a 2.0 mm burr in the same manner (Figure 4(d)). After changing the guidewire, bifur- enter the LAD and LCX because of the severe calci ed nodule at the distal LM (Figure 4(b)). Using a 130 cm long cation intervention was performed using a DK crush tech- coronary microcatheter (Finecross, Terumo, Japan), the nique to treat the LM, LAD, and LCX (Figures 4(e) and 4(f)). guidewire in the LCX was replaced with a 330 cm long RotaWire (Boston Scienti c Corporation, Massachusetts) in 2.4. Ethical Approval.  e study was approved by the In- anticipation of RA through ABU 3.75GC.  en, the pro- tective microcatheter and guidewire were placed in the stitutional Ethics Committees of Union Hospital, Tongji Medical College, Huazhong University of Science and dominant LAD through the ABU 3.5 GC. RA of the LM-LCX axis was performed with a 1.25 mm burr while protecting the Technology.  e approval number was 20210731. Journal of Interventional Cardiology 5 (a) (b) Rotational atherectomy device over LAD wire Microcatheter over LAD wire Rotational atherectomy device over LCX wire Microcatheter over LCX wire (c) (d) (e) (f ) Figure 4: Microcatheter-protected RA with the double GC in patient 2 (a) Left coronary angiography revealing severe calci ed LM bifurcation stenosis in caudal view. (b) IVUS showing severe calci ed nodule at the distal LM. (c) RA performed on the LM-LCX axis via the rst GC (7-F ABU 3.75 GC) with a 1.25 mm burr and the LAD protected by the microcatheter and guidewire through the second GC (7-F ABU 3.5 GC). (d) RA performed on the LM-LAD axis via the rst GC (7-F ABU 3.75 GC) with a 1.25 mm burr and the LCX protected by the microcatheter and guidewire through the second GC (7-F ABU 3.5 GC). (e) Final kissing balloon with noncompliant balloons to optimize the LM reconstruction. (f) Final postintervention coronary angiography in caudal view. RA, rotational atherectomy; GC, guiding catheter; IVUS, intravascular ultrasound; LM, left main coronary artery; LCX, left circum—ex coronary artery; LAD, left anterior descending coronary artery; RAO, right anterior oblique. 2.5. Statistical Analysis. SPSS version 15.0 (SPSS Inc., Chi- protect the LCX and LAD.  e damage rates of the pro- cago, IL, USA) for Windows was used for statistical analyses. tective microcatheters (66.7%, 4 of 6) or guidewires (33.3%, 2 Categorical variables are expressed as numbers and fre- of 6) in the 2.5 LM group were obviously lower than those in quencies. Dišerences in categorical variables were measured the <2.5 LM group (microcatheter: 100%, 12 of 12; guide- by the chi-square test. P < 0.05 was accepted as a signi cant wire: 100%, 12 of 12) (Table 2).  is suggested that the large dišerence in the analyses. space of distal LM can avoid friction and damage to the protective microcatheter and guidewire when the RA burrs 3. Result pass through. Although most microcatheters and guidewires were damaged to varying degrees, none of them was 3.1. In Vitro Experiments. All the RA burrs successfully completely fractured (Figures 5, Tables 1 and 2). passed through the simulated calci ed vascular stenosis. Most of the microcatheters (88.9%, 16 of 18) and guidewires (77.8%, 14 of 18) in the side branch were damaged after RA 3.2. Clinical Practice. In clinical practice, we successfully (Table 1).  ere was no signi cant dišerence in the prob- carried out two cases of microcatheter-protected RA with the ability of damage to the microcatheter or guidewire used to double GC technique for severely calci ed LM bifurcation. 6 Journal of Interventional Cardiology Table 1: In vitro rotational atherectomy outcome. RA of LM-LAD (n  9) RA of LM-LCX (n  9) P value Microcatheter damage 8 (88.9%) 8 (88.9%) 1.000 Guidewire damage 8 (88.9%) 6 (66.7%) 0.257 Microcatheter completely fracture 0 0 Guidewire completely fracture 0 0 Data are presented as number (%); RA, rotational atherectomy; LM, left main coronary artery; LAD, left anterior descending coronary artery; LCX, left circum—ex coronary artery. Table 2: Outcome of in vitro rotational atherectomy with dišerent LM sizes. RA of <2.5 LM (n  12) RA of 2.5 LM (n  6) P value Microcatheter damage 12 (100%) 4 (66.7%) 0.034 Guidewire damage 12 (100%) 2 (33.3%) 0.001 Microcatheter completely fracture 0 0 Guidewire completely fracture 0 0 Data are presented as number (%). RA, rotational atherectomy; LM, left main coronary artery; <2.5 LM, the diameter of the distal LM of vascular simulators was less than 2.5 mm, which including 2.0 mm and 2.25 mm; 2.5 LM, the diameter of the distal LM of vascular simulators was 2.5 mm. (a) (b) (c) (d) (e) (f ) Figure 5:  e representative damage of the microcatheters and guidewires after RA of vascular simulator with dišerent diameters of distal LM. (a)-(b)  e microcatheter and guidewire after RA of the 2.0LM vascular stimulator. (c)-(d)  e microcatheter and guidewire after RA of the 2.25 LM vascular stimulator. (e, f)  e microcatheter and guidewire after RA of the 2.5 LM vascular stimulator. RA, rotational atherectomy; LM, left main coronary artery; 2.0 LM/2.25LM/2.5LM, the diameter of the distal LM of vascular simulators was 2.0 mm/ 2.25 mm/2.5 mm. Journal of Interventional Cardiology 7 (a) (b) Figure 6:  e damage condition of the microcatheters after RA in clinical practice.  e microcatheter after RA of patient 1 (a) and patient 2 (b). RA, rotational atherectomy.  e microcatheters of patient 1 and patient 2 were both the side branch protective microcatheters and guidewires in damaged (Figure 6), but none of them were completely the 2.5 LM group had a smaller proportion of damage, sug- fractured. gesting that the large end space of the distal LM can reduce the friction and damage to the protective microcatheter and guidewire when the RA burr passes through. 4. Discussion  e possibility that debris shed from the microcatheter and guidewire would increase the probability of no-re—ow/ Acute occlusion of the LAD branch or LCX branch due to a slowre—ow which cannot betotally ignored. us,considering carina or plaque shift will cause major adverse outcomes in the distinction between the real calci ed human blood vessel PCI of true LM (Medina 1, 1, 1) bifurcation. It is known that and the vascular calci cation simulator, measures should be the calci ed coronary bifurcation lesions indicate a higher prepared to handle situations in which the protective risk of side branch occlusion [2].  erefore, side branch microcatheter or guidewire is completely fractured and be- protection during PCI of LM calci ed bifurcations has comes an intravascular foreign body in clinical practice. become mandatory. At present, there are several interven- tional treatments for coronary calci cation, such as focused force dilatation balloons, scoring balloons, cutting balloons, 5. Conclusion rotational atherectomy, orbital atherectomy, and coronary  e RA of severely calci ed LM bifurcation lesions may be intravascular lithotripsy [3]. Rotational atherectomy is a successfully performed using microcatheter-protected RA routine and e©cient interventional treatment for coronary with the double GC technique, potentially reducing the risk calci ed lesions. It forms a new channel by plaque modi- of side branch occlusion. Since the majority of protective cation after polishing of the calci ed plaque, which is microcatheters or guidewires were damaged, there was still convenient for the passage of subsequent instruments and some risk, and it is recommended to use this technique only conducive to the success of balloon expansion [5]. For bi- in highly selected patient population of severely calci ed true furcation lesions, during the performance of RA, only the (Medina 1, 1, 1) LM bifurcations. RotaWire should be placed in the target vessel to avoid cutting other guidewires and preventing guidewire en- trapment with burr rotation [4, 6]. Unfortunately, some Data Availability researchers have reported that the proportion of side branch  e data used to support the ndings of this study are in- occlusion caused by direct coronary RA is as high as 7.5% cluded within the article and supplementary information le. [7], which would be disastrous in the PCI of LM bifurcation. Protecting the side branch —ow has become a di©cult problem for cardiovascular interventional doctors. Conflicts of Interest Microcatheter-protected RA with the double GC tech-  e authors declare that they have no con—icts of interest. nique is an ešective method to protect the side branch during PCI of severely calci ed LM bifurcations, which was rst re- ported by Medda et al. in 2019. However, if the microcatheter Authors’ Contributions or guidewire used to protect the side branch is completely fractured during RA, it might become an intravascular foreign Shijun Yang, Silai Dong, Yanzhao Zhou, and Yumiao Wei body that can hardly be removed, with the occurrence of contributed equally to this work. possible complications such as acute LM thrombosis. To avoid potential risk, we carried out an in vitro experiment to assess Acknowledgments the safety of this method.  e in vitro experimental results showed that although the side branch protective micro-  e authors wish to thank Boston Scienti c Corporation catheters and guidewires were damaged to varying degrees which provides free rotational atherectomy burrs, Rota- after RA, all the side branch protective microcatheters and Wires, and coronary calci cation vascular simulators for in guidewires were not completely fractured. On the other hand, vitro study. 8 Journal of Interventional Cardiology Supplementary Materials Video 1. RA of the LM-LAD axis was performed with a 1.25mm burr in vitro. Video 2. RA of the LM-LCX axis was performed with a 1.25mm burr in vitro. Video 3. Patient 1 coronary angiography in LAO-caudal view. Video 4. Patient 1 RA of the LM-LCX axis was performed with a 1.25mm burr. Video 5. Patient 1 RA of the LM-LAD axis was per- formed with a 1.25mm burr. Video 6. Patient 2 coronary angiography in caudal view. Video 7. Patient 2 RA of the LM-LCX axis was performed with a 1.25mm burr. Video 8. Patient 2 RA of the LM-LAD axis was performed with a 1.25mm burr. Supplementary videos can be viewed through the shared Google Drive link: https://drive.google.com/ drive/folders/14ZTLcn_YtknxrzVwcRGzNnnHnpz8GNpj? usp=sharing. (Supplementary Materials) References [1] F. J. Sawaya, T. Lefevre, B. Chevalier et al., “Contemporary approach to coronary bifurcation lesion treatment,” JACC: Cardiovascular Interventions, vol. 9, no. 18, pp. 1861–1878, [2] Y. Fujino, G. F. Attizzani, S. Tahara et al., “Impact of main- branch calcified plaque on side-branch stenosis in bifurcation stenting: an optical coherence tomography study,” Interna- tional Journal of Cardiology, vol. 176, no. 3, pp. 1056–1060, [3] M. Perfetti, F. Fulgenzi, F. Radico et al., “Calcific lesion preparation for coronary bifurcation stenting,” Cardiology Journal, vol. 26, no. 5, pp. 429–437, 2019. [4] M. Medda, F. Casilli, M. Bande, and M. Tespili, “Protected rotationalatherectomywith double-guidingcathetertechnique for unprotected distal left main,” JACC: Cardiovascular In- terventions, vol. 12, no. 4, pp. e27–e29, 2019. [5] G. Iannopollo, F. Gallo, A. Mangieri et al., “Tips and tricks for rotational atherectomy,”JournalofInvasiveCardiology,vol. 31, no. 12, pp. E376–E383, 2019. [6] S. K. Sharma, M. I. Tomey, P. S. Teirstein et al., “North American expert review of rotational atherectomy,” Circula- tion: Cardiovascular Interventions, vol. 12, no. 5, Article ID e007448, 2019. [7] A.S.Walton,E.V.Pomerantsev,S.N.Oesterleetal.,“Outcome of narrowing related side branches after high-speed rotational atherectomy,” 2e American Journal of Cardiology, vol. 77, no. 5, pp. 370–373, 1996. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Interventional Cardiology Hindawi Publishing Corporation

Safety Assessment of Microcatheter-Protected Rotational Atherectomy with the Double Guiding Catheter Technique for Severely Calcified Left Main Bifurcation

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Hindawi Journal of Interventional Cardiology Volume 2022, Article ID 1399510, 8 pages https://doi.org/10.1155/2022/1399510 Research Article Safety Assessment of Microcatheter-Protected Rotational Atherectomy with the Double Guiding Catheter Technique for Severely Calcified Left Main Bifurcation Shijun Yang , Silai Dong, Yanzhao Zhou, Yumiao Wei, Ning Zhao, Chunhua Sun, and Xiang Cheng Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China Correspondence should be addressed to Xiang Cheng; nathancx@hust.edu.cn Received 10 April 2022; Revised 23 June 2022; Accepted 25 June 2022; Published 9 August 2022 Academic Editor: Joseph Dens Copyright © 2022 Shijun Yang et al. )is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Rotational atherectomy (RA) is a tool for calcium modification, but there is a risk of losing the side branch in left maincoronaryartery(LM)bifurcationlesions,resultingindisastrousconsequences.Microcatheter-protectedRA withthedouble guiding catheter (GC) technique for severely calcified LM bifurcations has been described previously, but its safety warrants further investigation. Methods. Various sizes of coronary calcification vascular simulators were utilized to model calcified LM bifurcation lesions for RA in in vitro. )e damage to the side branch protective microcatheters and guidewires was accessed after microcatheter-protected RA with the double GC technique. In clinical practice, microcatheter-protected RA with the double GC technique was carried out in two patients. Results. In vitro, none of the protective microcatheters or guidewires were completely fractured, although the majority of them were damaged to varying degrees. In clinical practice, we successfully carried out two cases of percutaneous coronary intervention for severely calcified LM bifurcation with microcatheter-protected RA using the double GC technique. Conclusion. RA of severely calcified LM bifurcation lesions may be successfully performed using microcatheter-protected RA with the double GC technique, potentially reducing the risk of side branch occlusion. Since majority of protective microcatheters or guidewires were damaged, there was still some risk, and it is recommended to use this technique only in highly selected patient population of severely calcified true (Medina 1, 1, 1) LM bifurcations. protected RA with the double guiding catheter (GC) tech- 1. Introduction nique, which has been reported in the past [4], raises Percutaneous coronary intervention (PCI) of lesions at left concerns about safety (especially the possibility of complete main (LM) bifurcations is consistently deemed a technical fracture of the protective microcatheter and guidewires). challengebecauseofthehighincidenceofcomplicationsand )us, we applied this technique in vitro to confirm its safety inferior clinical outcomes compared to those of non- and successfully performed the technique on two patients bifurcation lesions. Bifurcation coronary artery intervention with severely calcified LM bifurcations. may increase the risk of occlusion of a sidebranch due to the carinal shift while handling (via a balloon, atherectomy, or 2. Methods stent) the main branch [1]. Fujino et al. found that coronary bifurcation lesions with calcification predicted a higher risk 2.1. Materials Preparation. Microcatheters (130cm, Fine- of side branch occlusion [2]. Plaque modification with ro- cross, Terumo, Japan), 7-F ABU 3.5GC (APT Medical, tational atherectomy (RA) may reduce this risk, but the China),coronaryguidewire(AsahiSion,ASAHI,Japan),7-F associated side branch compromise still needs to be con- EBU 3.5GC (Medtronic, USA), the extracorporeal coronary sidered [3]. As an alternative solution, microcatheter- vascular simulator (Boston Scientific Corporation, USA), 2 Journal of Interventional Cardiology E G F H Figure 1: Extracorporeal coronary vascular simulator. (a) LM of the coronary vascular simulator. (b) LAD of the coronary vascular simulator. (c) 7-F ABU 3.5 GC (APT Medical, China). (d) 330 cm long RotaWire (Boston Scienti c Corporation, Massachusetts). (e) LCX of the coronary vascular simulator. (f) 7-F EBU 3.5 GC (Medtronic, USA). (g) Coronary microcatheter (Finecross, Terumo, Japan). (h) 180 cm long coronary guidewire (Asahi Sion, ASAHI, Japan). LM, left main coronary artery; LAD, left anterior descending coronary artery; GC, guiding catheter; LCX, left circum—ex coronary artery. and the 330 cm long RotaWire (Boston Scienti c Corpo- circum—ex artery(LCX) throughthesecondGC.  e RAof the ration, USA) were prepared. LM-LAD axis was performed with a 1.25 mm burr while protecting the LCX with the microcatheter (Figure 1, Sup- plementary Video 1). When RA of the LM-LCX axis was 2.2. In Vitro Experiment. An extracorporeal coronary vas- performed with a 1.25 mm burr, the microcatheter was placed cular simulator (Boston Scienti c Corporation, USA, Fig- in the LAD to protect the LAD in the same manner (Sup- ure 1) was used to simulate calci ed lesions.  ree sizes of plementaryVideo2). edamagetothesidebranchprotective coronary calci cation vascular simulators (Figure 2) were microcatheter and guidewire was evaluated after RA from the used for microcatheter-protected RA with the double GC dišerently sized calci ed lesion simulators. Observation and technique.  e steps are as follows: A 7-F ABU 3.5 GC (APT research indicators were as follows: number of damaged Medical, China) was used to engage the LM. A 180 cm long microcatheters, number of damaged guidewires, and number coronary guidewire (Asahi Sion, ASAHI, Japan) was inserted of completely fractured microcatheters or guidewires. into the left anterior descending artery (LAD) and was then replaced by a 330 cm long RotaWire through a coronary microcatheter in the anticipation of RA. Next, a 7-F EBU 2.3. Clinical Practice 3.5GC (Medtronic, USA) was used to engage the LM. A 180 cm long coronary guidewire with a 130 cm long micro- 2.3.1. Patient 1. A 75-year-old female with diabetes mellitus catheter (protective microcatheter) was placed into the left and hypertension presented with a 2-week history of chest Journal of Interventional Cardiology 3 5.0 mm 4.0 mm LM 1.25 mm 2.0 mm 1.25 mm LCX LAD 2.75 mm 3.0 mm (a) (b) 5.0 mm 4.0 mm LM 1.25 mm 2.25 mm 1.25 mm LCX LAD 2.75 mm 3.0 mm (c) (d) 5.0 mm 4.0 mm LM 1.25 mm 2.5 mm 1.25 mm LCX LAD 2.75 mm 3.0 mm (e) (f ) Figure 2: Structure diagram and real object of the coronary calci cation vascular simulator with dišerent diameters of distal LM. (a)-(b)  e diameters of distal LM are 2.0 mm. (c)-(d)  e diameters of distal LM are 2.25 mm. (e)-(f)  e diameters of distal LM are 2.5 mm. LM, left main coronary artery; LAD, left anterior descending coronary artery; LCX, left circum—ex coronary artery. tightness on exertion. Coronary angiography revealed se- microcatheter (Figure 3(c), Supplementary Video 4).  en, verely calci ed bifurcation stenosis of the LM, LAD, and the microcatheter was removed from the LAD and advanced LCX coronary arteries (Figure 3(a), Supplementary Video over the LCX guidewire into the LCX.  e RA of the LM- 3).  e patient refused to undergo cardiac surgery, and PCI LAD axis was performed with a 1.25 mm burr (Supple- was performed as an alternative treatment. mentary Video 5) and a 1.75 mm burr in the same manner A 7-F ABU 3.5GC (APT Medical, China) was used to (Figure 3(d)). After changing the guidewire, bifurcation engage the LM. Two 180 cm long coronary guidewires were intervention was performed using a double kissing crush inserted into the LAD and LCX. Intravascular ultrasound (DK crush) technique to treat the LM, LAD, and LCX (Figures 3(e) and 3(f)). (IVUS) was used to detect the LAD, LCX, and LM. IVUS showed calci cation throughout the whole course of the LM (Figure 3(b)). Using a 130 cm long coronary microcatheter 2.3.2. Patient 2. A 77-year-old male with diabetes mellitus (Finecross, Terumo, Japan), the coronary guidewire in the LCX was replaced with a 330 cm long RotaWire (Boston and hypertension presented with angina on exertion, which he had experienced for 4 months. Coronary angiography Scienti c Corporation, Massachusetts) in anticipation of RA.  en, a 7-F ABU 3.0 GC (APT Medical, China) was used revealed a severely calci ed bifurcation lesion at the end of the LM, with involvement of the ostia of both the LAD and to engage the LM.  e protective microcatheter and guidewire were placed in the dominant LAD through the LCX (Figure 4(a), Supplementary Video 6).  e patient strongly refused coronary artery bypass grafting and second GC.  e RA of the LM-LCX axis was performed with a 1.25 mm burr while protecting the LAD with the requested percutaneous coronary intervention. 4 Journal of Interventional Cardiology (a) (b) Rotational atherectomy device over LAD wire Microcatheter over LAD wire Rotational atherectomy device over LCX wire Microcatheter over LCX wire (c) (d) (e) (f ) Figure 3: Microcatheter-protected RA with the double GC in patient 1 (a) Left coronary angiography revealing severe calci ed LM bifurcation stenosis in LAO-caudal view. (b) IVUS showing severe calci cation in distal LM. (c) RA performed on the LM-LCX axis via the rst GC (7-F ABU 3.5 GC) with a 1.25 mm burr and the LAD protected by the microcatheter and guidewire through the second GC (7-F ABU 3.0 GC). (d) RA performed on the LM-LAD axis via the rst GC (7-F ABU 3.5 GC) with a 1.25 mm burr and the LCX protected by the microcatheter and guidewire through the second GC (7-F ABU 3.0 GC). (e) Final kissing balloon with noncompliant balloons to optimize the LM reconstruction. (f) Final postintervention coronary angiography in LAO-caudal view. RA, rotational atherectomy; GC, guiding catheter; LAO, left anterior oblique; IVUS, intravascular ultrasound; LM, left main coronary artery; LCX, left circum—ex coronary artery; LAD, left anterior descending coronary artery. A 7-F ABU 3.75GC (APT Medical, China) and a 7-F LAD with the microcatheter (Figure 4(c), Supplementary ABU 3.5GC (APT Medical, China) were used to engage the Video 7).  e microcatheter was removed from the LAD and LM. A 180 cm long coronary guidewire was passed into the advanced over the LCX guidewire into the LCX.  e RA of LAD and LCX through dišerent GCs. IVUS was used to the LM-LAD axis was performed with a 1.25 mm burr detect the LAD, LCX, and LM.  e IVUS probe could not (Supplementary Video 8) and a 2.0 mm burr in the same manner (Figure 4(d)). After changing the guidewire, bifur- enter the LAD and LCX because of the severe calci ed nodule at the distal LM (Figure 4(b)). Using a 130 cm long cation intervention was performed using a DK crush tech- coronary microcatheter (Finecross, Terumo, Japan), the nique to treat the LM, LAD, and LCX (Figures 4(e) and 4(f)). guidewire in the LCX was replaced with a 330 cm long RotaWire (Boston Scienti c Corporation, Massachusetts) in 2.4. Ethical Approval.  e study was approved by the In- anticipation of RA through ABU 3.75GC.  en, the pro- tective microcatheter and guidewire were placed in the stitutional Ethics Committees of Union Hospital, Tongji Medical College, Huazhong University of Science and dominant LAD through the ABU 3.5 GC. RA of the LM-LCX axis was performed with a 1.25 mm burr while protecting the Technology.  e approval number was 20210731. Journal of Interventional Cardiology 5 (a) (b) Rotational atherectomy device over LAD wire Microcatheter over LAD wire Rotational atherectomy device over LCX wire Microcatheter over LCX wire (c) (d) (e) (f ) Figure 4: Microcatheter-protected RA with the double GC in patient 2 (a) Left coronary angiography revealing severe calci ed LM bifurcation stenosis in caudal view. (b) IVUS showing severe calci ed nodule at the distal LM. (c) RA performed on the LM-LCX axis via the rst GC (7-F ABU 3.75 GC) with a 1.25 mm burr and the LAD protected by the microcatheter and guidewire through the second GC (7-F ABU 3.5 GC). (d) RA performed on the LM-LAD axis via the rst GC (7-F ABU 3.75 GC) with a 1.25 mm burr and the LCX protected by the microcatheter and guidewire through the second GC (7-F ABU 3.5 GC). (e) Final kissing balloon with noncompliant balloons to optimize the LM reconstruction. (f) Final postintervention coronary angiography in caudal view. RA, rotational atherectomy; GC, guiding catheter; IVUS, intravascular ultrasound; LM, left main coronary artery; LCX, left circum—ex coronary artery; LAD, left anterior descending coronary artery; RAO, right anterior oblique. 2.5. Statistical Analysis. SPSS version 15.0 (SPSS Inc., Chi- protect the LCX and LAD.  e damage rates of the pro- cago, IL, USA) for Windows was used for statistical analyses. tective microcatheters (66.7%, 4 of 6) or guidewires (33.3%, 2 Categorical variables are expressed as numbers and fre- of 6) in the 2.5 LM group were obviously lower than those in quencies. Dišerences in categorical variables were measured the <2.5 LM group (microcatheter: 100%, 12 of 12; guide- by the chi-square test. P < 0.05 was accepted as a signi cant wire: 100%, 12 of 12) (Table 2).  is suggested that the large dišerence in the analyses. space of distal LM can avoid friction and damage to the protective microcatheter and guidewire when the RA burrs 3. Result pass through. Although most microcatheters and guidewires were damaged to varying degrees, none of them was 3.1. In Vitro Experiments. All the RA burrs successfully completely fractured (Figures 5, Tables 1 and 2). passed through the simulated calci ed vascular stenosis. Most of the microcatheters (88.9%, 16 of 18) and guidewires (77.8%, 14 of 18) in the side branch were damaged after RA 3.2. Clinical Practice. In clinical practice, we successfully (Table 1).  ere was no signi cant dišerence in the prob- carried out two cases of microcatheter-protected RA with the ability of damage to the microcatheter or guidewire used to double GC technique for severely calci ed LM bifurcation. 6 Journal of Interventional Cardiology Table 1: In vitro rotational atherectomy outcome. RA of LM-LAD (n  9) RA of LM-LCX (n  9) P value Microcatheter damage 8 (88.9%) 8 (88.9%) 1.000 Guidewire damage 8 (88.9%) 6 (66.7%) 0.257 Microcatheter completely fracture 0 0 Guidewire completely fracture 0 0 Data are presented as number (%); RA, rotational atherectomy; LM, left main coronary artery; LAD, left anterior descending coronary artery; LCX, left circum—ex coronary artery. Table 2: Outcome of in vitro rotational atherectomy with dišerent LM sizes. RA of <2.5 LM (n  12) RA of 2.5 LM (n  6) P value Microcatheter damage 12 (100%) 4 (66.7%) 0.034 Guidewire damage 12 (100%) 2 (33.3%) 0.001 Microcatheter completely fracture 0 0 Guidewire completely fracture 0 0 Data are presented as number (%). RA, rotational atherectomy; LM, left main coronary artery; <2.5 LM, the diameter of the distal LM of vascular simulators was less than 2.5 mm, which including 2.0 mm and 2.25 mm; 2.5 LM, the diameter of the distal LM of vascular simulators was 2.5 mm. (a) (b) (c) (d) (e) (f ) Figure 5:  e representative damage of the microcatheters and guidewires after RA of vascular simulator with dišerent diameters of distal LM. (a)-(b)  e microcatheter and guidewire after RA of the 2.0LM vascular stimulator. (c)-(d)  e microcatheter and guidewire after RA of the 2.25 LM vascular stimulator. (e, f)  e microcatheter and guidewire after RA of the 2.5 LM vascular stimulator. RA, rotational atherectomy; LM, left main coronary artery; 2.0 LM/2.25LM/2.5LM, the diameter of the distal LM of vascular simulators was 2.0 mm/ 2.25 mm/2.5 mm. Journal of Interventional Cardiology 7 (a) (b) Figure 6:  e damage condition of the microcatheters after RA in clinical practice.  e microcatheter after RA of patient 1 (a) and patient 2 (b). RA, rotational atherectomy.  e microcatheters of patient 1 and patient 2 were both the side branch protective microcatheters and guidewires in damaged (Figure 6), but none of them were completely the 2.5 LM group had a smaller proportion of damage, sug- fractured. gesting that the large end space of the distal LM can reduce the friction and damage to the protective microcatheter and guidewire when the RA burr passes through. 4. Discussion  e possibility that debris shed from the microcatheter and guidewire would increase the probability of no-re—ow/ Acute occlusion of the LAD branch or LCX branch due to a slowre—ow which cannot betotally ignored. us,considering carina or plaque shift will cause major adverse outcomes in the distinction between the real calci ed human blood vessel PCI of true LM (Medina 1, 1, 1) bifurcation. It is known that and the vascular calci cation simulator, measures should be the calci ed coronary bifurcation lesions indicate a higher prepared to handle situations in which the protective risk of side branch occlusion [2].  erefore, side branch microcatheter or guidewire is completely fractured and be- protection during PCI of LM calci ed bifurcations has comes an intravascular foreign body in clinical practice. become mandatory. At present, there are several interven- tional treatments for coronary calci cation, such as focused force dilatation balloons, scoring balloons, cutting balloons, 5. Conclusion rotational atherectomy, orbital atherectomy, and coronary  e RA of severely calci ed LM bifurcation lesions may be intravascular lithotripsy [3]. Rotational atherectomy is a successfully performed using microcatheter-protected RA routine and e©cient interventional treatment for coronary with the double GC technique, potentially reducing the risk calci ed lesions. It forms a new channel by plaque modi- of side branch occlusion. Since the majority of protective cation after polishing of the calci ed plaque, which is microcatheters or guidewires were damaged, there was still convenient for the passage of subsequent instruments and some risk, and it is recommended to use this technique only conducive to the success of balloon expansion [5]. For bi- in highly selected patient population of severely calci ed true furcation lesions, during the performance of RA, only the (Medina 1, 1, 1) LM bifurcations. RotaWire should be placed in the target vessel to avoid cutting other guidewires and preventing guidewire en- trapment with burr rotation [4, 6]. Unfortunately, some Data Availability researchers have reported that the proportion of side branch  e data used to support the ndings of this study are in- occlusion caused by direct coronary RA is as high as 7.5% cluded within the article and supplementary information le. [7], which would be disastrous in the PCI of LM bifurcation. Protecting the side branch —ow has become a di©cult problem for cardiovascular interventional doctors. Conflicts of Interest Microcatheter-protected RA with the double GC tech-  e authors declare that they have no con—icts of interest. nique is an ešective method to protect the side branch during PCI of severely calci ed LM bifurcations, which was rst re- ported by Medda et al. in 2019. However, if the microcatheter Authors’ Contributions or guidewire used to protect the side branch is completely fractured during RA, it might become an intravascular foreign Shijun Yang, Silai Dong, Yanzhao Zhou, and Yumiao Wei body that can hardly be removed, with the occurrence of contributed equally to this work. possible complications such as acute LM thrombosis. To avoid potential risk, we carried out an in vitro experiment to assess Acknowledgments the safety of this method.  e in vitro experimental results showed that although the side branch protective micro-  e authors wish to thank Boston Scienti c Corporation catheters and guidewires were damaged to varying degrees which provides free rotational atherectomy burrs, Rota- after RA, all the side branch protective microcatheters and Wires, and coronary calci cation vascular simulators for in guidewires were not completely fractured. On the other hand, vitro study. 8 Journal of Interventional Cardiology Supplementary Materials Video 1. RA of the LM-LAD axis was performed with a 1.25mm burr in vitro. Video 2. RA of the LM-LCX axis was performed with a 1.25mm burr in vitro. Video 3. Patient 1 coronary angiography in LAO-caudal view. Video 4. Patient 1 RA of the LM-LCX axis was performed with a 1.25mm burr. Video 5. Patient 1 RA of the LM-LAD axis was per- formed with a 1.25mm burr. Video 6. Patient 2 coronary angiography in caudal view. Video 7. Patient 2 RA of the LM-LCX axis was performed with a 1.25mm burr. Video 8. Patient 2 RA of the LM-LAD axis was performed with a 1.25mm burr. Supplementary videos can be viewed through the shared Google Drive link: https://drive.google.com/ drive/folders/14ZTLcn_YtknxrzVwcRGzNnnHnpz8GNpj? usp=sharing. (Supplementary Materials) References [1] F. J. Sawaya, T. Lefevre, B. Chevalier et al., “Contemporary approach to coronary bifurcation lesion treatment,” JACC: Cardiovascular Interventions, vol. 9, no. 18, pp. 1861–1878, [2] Y. Fujino, G. F. Attizzani, S. Tahara et al., “Impact of main- branch calcified plaque on side-branch stenosis in bifurcation stenting: an optical coherence tomography study,” Interna- tional Journal of Cardiology, vol. 176, no. 3, pp. 1056–1060, [3] M. Perfetti, F. Fulgenzi, F. Radico et al., “Calcific lesion preparation for coronary bifurcation stenting,” Cardiology Journal, vol. 26, no. 5, pp. 429–437, 2019. [4] M. Medda, F. Casilli, M. Bande, and M. Tespili, “Protected rotationalatherectomywith double-guidingcathetertechnique for unprotected distal left main,” JACC: Cardiovascular In- terventions, vol. 12, no. 4, pp. e27–e29, 2019. [5] G. Iannopollo, F. Gallo, A. Mangieri et al., “Tips and tricks for rotational atherectomy,”JournalofInvasiveCardiology,vol. 31, no. 12, pp. E376–E383, 2019. [6] S. K. Sharma, M. I. Tomey, P. S. Teirstein et al., “North American expert review of rotational atherectomy,” Circula- tion: Cardiovascular Interventions, vol. 12, no. 5, Article ID e007448, 2019. [7] A.S.Walton,E.V.Pomerantsev,S.N.Oesterleetal.,“Outcome of narrowing related side branches after high-speed rotational atherectomy,” 2e American Journal of Cardiology, vol. 77, no. 5, pp. 370–373, 1996.

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Journal of Interventional Cardiology – Hindawi Publishing Corporation

Published: Aug 9, 2022

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