Optical frequency domain imaging-guided rotational atherectomy followed by drug-coated balloon dilation to the non-calcified lesion in a patient with severe thrombocytopenia

Excerpt

A 77-year-old man with aplastic anemia was admitted to our hospital due to worsening heart failure. Approximately 1 year earlier, he underwent left main (LM)-left anterior descending coronary artery (LAD) crossover stenting with a bare metal stent (BMS) [1]. A routine blood test at admission showed pancytopenia (platelet 2000/μL, hemoglobin 6.3 g/dL, white blood cell 3120/μL) and coronary angiography (CAG) indicated a subtotal occlusion in the mid-distal right coronary artery (RCA) without in-stent restenosis of the BMS in LM-LAD (Supplementary Fig. 1). Because of refractory heart failure and severe thrombocytopenia, we performed transradial stentless percutaneous coronary intervention (PCI) against the RCA lesion after transfusions, using rotational atherectomy (RA) and drug-coated balloon (DCB) under aspirin and intravenous heparin (Fig. 1a). Pre-procedural optical frequency domain imaging (OFDI) showed diffuse fibrous plaque as well as micro channels and deep layered area with low-intensity signal particularly at proximal site of the lesion, suggesting presence of organized thrombus and healed plaque rupture (Fig. 1g–i). We performed RA with a 1.5-mm burr (initial 180,000 rpm) and a 1.75-mm burr (initial 160,000 rpm) (Fig. 1b), gradually advanced burrs using a careful slow-bumping motion, and modified burr speed gradually down to 120,000 rpm by 20,000 rpm during each ablation. During the RA procedure, no slow flow/no reflow occurred, and repeat OFDI confirmed gradual luminal enlargement and a relatively polished luminal border without major dissections, fresh thrombus, and deep gutter formation (Supplementary Fig. 2). Then, we advanced a guiding extension catheter, and inflated a DCB (2.0/20 mm) at 10 atm for 60 s in the distal part (Fig. 1c), and another DCB (2.5/30 mm) at 7 atm for 60 s in the proximal part (Fig. 1d), successively. Final CAG and OFDI showed an acceptable result without flow delay (Fig. 1e, f) and a relatively smooth luminal surface with minor dissections (Fig. 1j–l), respectively. After the procedure, we at first planned to continue the administration of aspirin 100 mg/day for 2 weeks; however, we had to exchange aspirin for intravenous infusion of heparin 3 days after the PCI because of a possibility of drug fever due to aspirin and then administered heparin infusion for 7 days. He has since been free of cardiovascular/hemorrhagic events without antiplatelet/anticoagulant therapy for 7 months.

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