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Rasoul Mokabberi and James C Blankenship
American Heart Journal Hospital Volume 8 No.1

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We describe successful rotational atherectomy performed in the setting of two relative contraindications to the procedure. A 77- year-old female presented with ST-segment-elevation myocardial infarction due to 100% right coronary artery thrombosis. With high pressure dilatation (22 atmospheres) and cutting balloon angioplasty, the lesion dissected but did not fully dilate. After stenting and high-pressure post-dilatation at 25 atmospheres the dissection resolved, but a 70% waist remained. Rotational atherectomy allowed full dilatation of the lesion at 22 atmospheres. In this case, after stenting removed angiographically evident thrombus and dissection, rotational atherectomy effectively and safely treated residual stenosis at an undilatable lesion.

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Percutaneous rotational coronary atherectomy (PRCA) facilitates stent delivery in diffuse, complex, heavily calcified lesions.¹ In patients with acute coronary syndromes and especially in acute myocardial infarction (MI), PRCA may cause distal embolization of thrombus resulting in slow-flow or no-reflow.^2,3 In patients with spontaneous or iatrogenic dissection, PRCA may cause perforation or extension of the dissection. Thus, PRCA is generally avoided in lesions that are thrombotic or dissected. In this article we report a patient with both thrombus and dissection at the culprit site, where PRCA facilitated safe and effective dilatation of a previously non-dilatable lesion.

Case Report
A 77-year-old female with hypertension, hyperlipidemia, prior stroke, and stage 3 chronic kidney disease presented with chest pain intermittently for four days, acutely worse for the past four hours. The pre-hospital 12-lead electrocardiogram showed inferior ST elevation. Aspirin, oxygen, morphine, and nitrates were given. The patient was brought directly to the cardiac catheterization laboratory from the ambulance.

Diagnostic left arteriography showed no severe disease. Left ventriculography demonstrated inferior hypokinesis and ejection fraction of 55%. A 6-French Judkins right guide catheter (Medtronic, Santa Rosa, CA) was used to demonstrate 100% right coronary stenosis with thrombolysis in myocardial infarction (TIMI) 0 flow (see Figure 1). Intravenous bivalirudin 0.75mg/kg bolus was given and an infusion was started at 1.75mg/kg/hour. A 0.014 Asahi soft wire (Abbott, Santa Rosa, CA) easily crossed the stenosis, immediately producing TIMI I–II distal flow and dramatic improvement in ST-segment elevation on the hemodynamic monitor. Manual aspiration was attempted with an aspiration catheter (Volcano Corporation, San Diego, CA), but no thrombus was obtained and the appearance and flow in the vessel were unchanged.

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