Thread by @ESC_Journals

1/25
How would you tackle this heavily calcified LAD with calcified #nodule that was appropriately identified by intravascular imaging? #OCT
doi.org/10.1093/ehjcr/…

In this #EHJCaseReports #tweetorial we take a deep dive into the Rx of #calcified coronary lesions.
#Cardiotwitter

2/25
Calcified lesions are top of the totem pole of complex PCI
Main armamentaria are balloon-based #IVL & ablation-based (rotational/orbital) techniques, while ancillary tools eg guide extension catheters are useful too. eurointervention.pcronline.com/article/intrav…

#EHJCaseReports #tweetorial

3/25
What do you see with this non-compliant balloon in this calcified RCA?
What would you do next? Poll in next tweet! doi.org/10.1093/ehjcr/…

4/25
#Poll
Balloon or stent dog-boning 🦴 is not uncommon with calcified lesions. What would be your next step? 👇

To find out what happened next: doi.org/10.1093/ehjcr/…

#EHJCaseReports #Tweetorial #Rotatripsy

5/25
Intravascular imaging is critical in calcified lesion PCI
When balloon-uncrossable, imaging catheters may not cross too
In this #rotatripsy case, optical coherence tomography post-IVL confirmed micro # in the calcium #OCT
doi.org/10.1093/ehjcr/…

6/25
The utility of intravascular imaging cannot be overstated in the Rx of calcified coronary lesions. What do you see on this #IVUS run of the prox-mid LAD in this pt who presented w NSTEMI?
His LAD was stented 15 yrs ago.
doi.org/10.1093/ehjcr/…

7/25
As: calcific neoatherosclerotic in-stent restenosis
See how #IVUS-guided #intravascular lithotripsy was used, complicated by #IVL balloon rupture & resolution of distal embolization with 🎈retrieval & IC nitroprusside.
doi.org/10.1093/ehjcr/…
#EHJCaseReports #tweetorial

8/25
Adequate lesion preparation in calcified vessels is key. Here’s another case of extreme dog-boning of 3 × 6 mm cutting balloon, even after rotablation w 1.5 mm burr. What do you think happened next?
doi.org/10.1093/ehjcr/…

9/25
#Rotablation is generally not done in presence of dissection & thrombus.
But in this non-dilatable #calcific LAD lesion, bailout rotablation was done where pt developed complete thrombotic occlusion doi.org/10.1093/ehjcr/…

10/25
Rotational atherectomy in left main w ACS can be tricky-#IVUS is key!
Here, a ping-pong 🏓guide technique was used to rotablate the LAD, so as to keep a wire in the LCx & complete the procedure w a DK Crush technique.
doi.org/10.1093/ehjcr/…

11/25
In calcified LM, there's ⬆️risk of slow/no reflow due to diffuse calcification & unfavourable wire bias
In this case of #Rotatripsy, synergistic effects of #rotablation then IVL were used, instead of upsizing the rota burr
doi.org/10.1093/ehjcr/…

12/25
While data for use in grafts is scarce, in this 83-year-old's calcified right internal mammary graft, rotational atherectomy was done (burr size 1.25mm) through graft using a guide extension catheter followed by stenting
doi.org/10.1093/ehjcr/…

13/25
Rotational atherectomy (#RA) can induce significant bradycardia or AV block requiring temporary #pacing.
See how trans-coronary pacing was done via a Rota wire to prevent bradycardia during RA in the pRCA.
doi.org/10.1093/ehjcr/…

14/25
Complications of #rotablation can be avoided w/good techniques.
This @EuroInterventio expert consensus document covers rotational atherectomy #RA protocols & complications mx
@EAPCIPresident eurointervention.pcronline.com/article/europe…

15/25
Rhythm-related problems can occur with IVL too
In this case of ventricular fibrillation induced by a lithotripsy-pulse on T, spontaneous circulation was re-established after 2 min of CPR with DC cardioversion.
doi.org/10.1093/ehjcr/…
#IVL

16/25
We know of "shocktopics" with intravascular #lithotripsy. But have you seen precipitation of de novo atrial fibrillation with #IVL after pacing capture? See how in this case of #IVL in pRCA.
doi.org/10.1093/ehjcr/…

17/25
#IVL is a game-changer: see how IVL was used to bailout an unexpanded stent in left main, which was implanted following an acute dissection by non-compliant balloon inflation. Again, intravascular imaging is 🔑
doi.org/10.1093/ehjcr/…

18/25
Could shockwave 🎈 be a bail-out strategy in stent underexpansion in primary PCI?
See how #IVUS guided #IVL was effectively used to correct stent underexpansion in this off-label indication of intravascular lithotripsy
doi.org/10.1093/ehjcr/…

19/25
Initial rotablation helps smooth delivery of higher profile IVL 🎈for further plaque modification but it isn't w/o complications: This type C dissection extending to LM ostium required emergent LM bifurcation stenting
doi.org/10.1093/ehjcr/…

20/25
Can a #lithotripsy balloon rupture? What do you see here?
To find out how this type E dissection was managed, read this fascinating case report.
doi.org/10.1093/ehjcr/…
#Shockwave

21/25
Optical Coherence Tomography #OCT is a great tool to delineate mechanism of stent underexpansion, esp with underlying #calcium.
In this case, intravascular #lithotripsy was used to Rx very late stent expansion. doi.org/10.1093/ehjcr/…
#IVL

22/25
Are all calcified plaques stable? Here, slow-flow, chest pain & ST elevation ensued after lesion dilatation with scoring balloon
See how near-infrared spectroscopy #NIRS helps assess procedural risk when #IVUS is not enough
doi.org/10.1093/ehjcr/…

23/25
Pts w calcified lesions needing complex PCI are often v ill & co-exist w severe AS requiring #TAVI
Such high-risk PCI has been undertaken with #IVL & upfront use of mechanical circulatory support
#MCS #ECMO #IABP
doi.org/10.1093/ehjcr/…

24/25
ROTAVI: calcified lesions never come alone!
In this case of calcified dLM bifurcation and concomitant severe AS, simultaneous LM rotablation (1.5 mm burr) PCI & #TAVI were performed
doi.org/10.1093/ehjcr/…

25/25
We hope you enjoyed this #EHJCaseReports #tweetorial covering the myriad of presentations & options to treat #calcified coronary lesions. Remember to #ImageFirst before deciding on strategy!
Credit: @aayshacader
#SoMe team: @FarhanaAra @ANazmiCalik @KardiologieHH @TJ_Yeo