A 50-year-old woman was hospitalized on October, 2017 for ongoing limiting angina pectoris. The patient had a history of precordial chest pain for 4 years, and aggravation for 1 week. Four years ago, she was diagnosed unstable angina pectoris and old anterior myocardial infarction at local hospital. Angiography revealed triple vessel disease involving proximal LAD, middle LCX and middle RCA (Fig. 1), The patient underwent percutaneous coronary intervention (PCI) with 3 drug eluting stents (DESs) (2.5 mm × 33 mm, 2.5 mm × 18 mm and 2.5 mm × 23 mm) in RCA, and 1 DES (3 mm × 38 mm) in the LAD (Fig. 1). The patient’s symptoms relived after PCI, while secondary prevention medications were taken regularly (clopidogrel was stopped after one and a half years, aspirin continued). Past medical history includes type 2 diabetes for 21 years, hyperlipidemia for 4 years, left renal artery stenosis and underwent stenting for 1 year, diabetic foot necrosis and underwent left foot amputation for 5 months. She has no family history of coronary heart disease.
After hospitalization, physical examination was non-remarkable, and secondary prevention treatment was prescribed, troponin was negative, echocardiography revealed LVEF 45%. Coronary angiography revealed visible stents in the proximal and middle segments of RCA, with in-stent total occlusion (Fig. 2a), stent fracture could be seen at the second turning point of RCA (Fig. 2c and d). Stent was seen in proximal LAD, with mild intimal hyperplasia in the stent (50–60% diffused stenosis), 50–70% diffused stenosis in middle LCX and 70–85% diffused stenosis in proximal and middle of second obtuse marginal artery (OM2) (Fig. 2b). The patient was diagnosed unstable angina pectoris and old anterior myocardial infarction, and PCI was indicated.
As the ISR of RCA was CTO, which accompanied stent fracture, two difficulties present: ①it will be hard for the guidewire to traverse the lesion through true lumen. ②balloon expansion in the stent fracture region was expected to be difficult. Therefore, we performed transradial PCI using 6F AL1.0 guiding catheter, after GAIA second guidewire (Asahi Intec, Abbott Vascular, Rangendingen, Germany) traversed the lesion, neither microcatheter nor balloon anchored guidewire could pass the leision, so we used a 1.4 mm ELCA catheter (CVX-300, Spectranetics, CO, USA) with a pulse rate of 40 Hz and energy output of 45 mJ/mm2 to ablate ISR for 3 times (Fig. 3d). Then a Finecross MG catheter (Terumo Medical Corp., NJ, USA; 1.8 Fr) was applied to exchange for the Rota Wire, so that Rota Wire could be easily advanced to distal RCA. Then, RA was performed using a 1.25-mm burr (RotaLink, Boston Scientific) at the speed of 170,000 r/min for 75 s to fully debulk the lesion (Fig. 3e and f), IVUS showed 90°-270° calcification and stent fracture (Additional file 1: Figure S1), followed by the deployment of one drug-eluting stent (2.75 mm*24 mm, Fig. 4a and b). Intravascular ultrasound (IVUS) revealed well attachment of the stent (Fig. 4c and d), and the patient was discharged without complication 3 days later, echocardiography revealed LVEF 60%(Additional file 2: Figure S2). The patient was followed up for 10 months and no recurrent chest discomfort was reported, no adverse event was reported, echocardiography revealed LVEF 64%.
