Using Orbital Atherectomy in ST-Elevation Myocardial Infarction: A Case Report From a Nonsurgical Centre

Coronary artery calcification significantly complicates percutaneous coronary intervention (PCI), particularly in acute myocardial infarction (AMI), where rapid revascularisation is essential. In ST-elevation myocardial infarction (STEMI) with heavily calcified culprit lesions, conventional strategies often fail due to lesion rigidity. Orbital atherectomy (OA) has emerged as an effective technique for modifying calcified plaques and improving stent delivery. However, its use in STEMI and in nontertiary centres such as district general hospitals (DGHs) remains underreported.

A 61-year-old man with a history of smoking and hypertension presented with inferior STEMI and hemodynamic instability. Coronary angiography revealed heavy calcification and occlusion of the proximal right coronary artery (RCA). Initial attempts using standard wires, microcatheters, and parallel wiring were unsuccessful. The lesion was successfully crossed using a ViperWire, enabling OA. Subsequent adjunctive therapies achieved optimal vessel preparation and revascularisation, including intravascular lithotripsy (IVL), intravascular ultrasound (IVUS)-guided stenting, and postdilation. The patient recovered uneventfully and was discharged after 2 days, remaining asymptomatic and compliant with secondary prevention at 6 weeks. This case highlights the feasibility of OA in STEMI with severe calcification in a DGH without onsite surgical cover. Careful planning, operator expertise and multidisciplinary collaboration enabled a favourable outcome despite procedural challenges.

The case stresses the need for broader access to advanced PCI tools, enhanced training and standardised protocols in resource-limited settings. Further studies and real-world data are essential to evaluate the long-term safety and efficacy of OA in acute settings.