Desperate times, desperate measures: rotablating dissections in acute myocardial infarction

The concomitant existence of an acute ST elevation myocardial infarction (STEMI) and a truly undilatable lesion is not a common occurrence, although STEMI lesions can be calcified and sometimes difficult to fracture. The manufacturer lists the presence of a dissection as a contraindication to use for rotational atherectomy. There are no previously reported cases in the literature of rotablation of significant macro dissections in the setting of acute myocardial infarction (MI). Noncompliant balloons, the Cutting Balloon Ultra (Boston Scientific), the Fx miniRAIL™ (Abbott Vascular), and the "cutting wire" technique have all been previously described for calcific lesion modification.1 Heavily calcific lesions especially in the setting of a thrombotic infarction may predispose to under expansion, restenosis, and stent thrombosis. Rotational atherectomy (RA) through plaque ablation and altering arterial wall compliance may be helpful in negotiating heavily calcific lesions.2 Previously, a single case report of the use of RA in the setting of a STEMI has been reported.3 Two previous RA reports have been de- scribed in the setting of acute and delayed healing of dissections; however neither were in the setting of acute STEMI.4,5 We describe the first report to our knowledge of RA for a truly undilatable lesion with accompanying NHLBI type C iatrogenic dissection post balloon dilation during an acute STEMI to allow lesion fracture and subsequent stent deployment.