Distal embolization of coronary calcified nodule after rotational atherectomy

Area of Science:

• Interventional Cardiology
• Cardiovascular Imaging
• Vascular Biology

Background:

• Percutaneous coronary intervention (PCI) is a common treatment for coronary artery disease.
• Severely calcified lesions, particularly those with calcified nodules, pose significant challenges during PCI.
• Intravascular imaging modalities like optical frequency domain imaging (OFDI) are crucial for characterizing complex lesions.

Observation:

• A 62-year-old man with effort angina presented with a severely calcified lesion in the mid-right coronary artery.
• Pre-procedural OFDI revealed a calcified nodule.
• Initial rotational atherectomy with a 2.0 mm burr increased lumen area, but significant calcification persisted.

Findings:

• Attempting a larger burr (2.25 mm) for rotational atherectomy resulted in distal embolization of the calcified nodule.
• Embolus retrieval failed; balloon angioplasty was performed, but recoil occurred.
• Successful implantation of a drug-eluting stent in the affected segments achieved good expansion, compressing the calcified nodule outside the stent.

Implications:

• Rotational atherectomy can be effective for achieving stent expansion and reducing perforation risk in calcified nodules.
• Distal embolization is a significant complication to anticipate and manage during rotational atherectomy for calcified nodules.
• Careful procedural planning and imaging are essential for optimizing outcomes in complex calcified coronary lesions.