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Recreating the Crime Scene: Three-Dimensional Model to Analyze the Mechanism of Orbital Atherectomy-Related Coronary Perforation

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J INVASIVE CARDIOL 2025. doi:10.25270/jic/25.00010. Epub January 31, 2025.


A 77-year-old woman with hypertension and diabetes presented with exertional angina and dyspnea. Subsequent workup showed severe aortic stenosis (AS) and severe calcified stenosis at the proximal left anterior descending artery (pLAD) (Figure 1A and B). After discussion with the heart team, the patient planned to undergo transcatheter aortic valve implantation (TAVI) to tackle the critical AS, followed by percutaneous coronary intervention with atherectomy in the same setting.

Under local anesthesia, a 26-mm Evolut FX+ valve (Medtronic) was implanted from the femoral approach. Subsequently, a 7-French Judkins Left-4 guiding catheter engaged the left coronary artery from inside the TAVI valve. Intravascular ultrasound (IVUS) showed a huge calcified nodule extending from distal left main (dLM) to the pLAD (Figure 1C-E). Orbital atherectomy (OA) with a 1.25mm crown was performed from the dLM to the pLAD with two 80K runs antegrade and retrograde, followed by one 120K run antegrade and retrograde (Figure 1F). The patient developed severe hypotension and contrast injection showed Ellis type III perforation at the pLAD (Figure 1G). Echocardiography confirmed cardiac tamponade, and pericardiocentesis was performed, which yielded fresh blood. Intracoronary balloon tamponade and covered stent implantation failed to achieve hemostasis. Emergency open heart surgery with TAVI explant, Bentall, and coronary bypass were performed. The patient recovered and was discharged 9 days post-procedure.

OA is an important tool for management of severe calcified coronary artery disease.1 Coronary perforation related to OA is an uncommon but acute complication. In this case, IVUS showed that the wire was heavily biased against the healthy vessel wall at the pLAD. The trajectory of the crown could cause injury to the vessel wall instead of ablating the calcified nodule.2 Using coronary computed tomography angiogram (Figure 2A-C), we created a 3D-printed Polyjet heart model (Stratasys) to simulate the OA process. The calcified nodule was located at the infero-anterior side of the dLM to the pLAD, but the wire and OA were biased toward the supero-posterior side of the pLAD (Figure 2D and E, Video). This caused injury to the vessel wall and eventually led to perforation at the corresponding site. This case illustrates the possible mechanism of OA-associated vessel perforation and the importance of IVUS to identify the wire bias to guide atherectomy procedures.

 

Figure 1
Figure 1. Orbital atherectomy-induced coronary perforation. (A, B) Coronary angiogram showed the calcified nodule (white arrow) causing severe stenosis at the pLAD. (C-E) Intravascular ultrasound demonstrated the calcified nodule (*) extending from the dLM to the pLAD; the coronary wire was biased against the healthy vessel wall. (F) Orbital atherectomy was performed from the dLM to the pLAD. (G) Contrast injection showed contrast extravasation at the pLAD. dLM = distal left main; LAD = left anterior descending artery; pLAD = proximal left anterior descending artery.

 

Figure 2
Figure 2. Three-dimensional (3D) printed simulation model. (A-C) Coronary computed tomography showed heavy calcification that was predominantly located at the inferior side of the dLM, pLAD, and proximal circumflex artery. (D, E) The 3D printed model viewed from superior and anterior side, respectively. (D2-D4, E2-E4) The wire and orbital crown ablated the supero-posterior side (white arrowhead) of the vessel wall. dLM = distal left main; pLAD = proximal left anterior descending artery.

 

Affiliations and Disclosures

Chor-Cheung Frankie Tam, MBBS1; Simon Lam, MBBS1; Michael Sze, MBBS1; Eric Chan, MBBS1; Chun Ka Wong, MBBS1; Chin Lung Wong, MBBS2; Christian Fang, MBBS2

From the 1Cardiology Division, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China; 2Department of Orthopedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and for the publication thereof.

Address for correspondence: Chor-Cheung Frankie Tam, MBBS, Cardiology Division, Department of Medicine, The University of Hong Kong, K19, Queen Mary Hospital, 102# Pok Fu Lam Road, Hong Kong, China. Email: frankie.tamcc@gmail.com

 

References

  1. Shlofmitz E, Martinsen BJ, Lee M, et al. Orbital atherectomy for the treatment of severely calcified coronary lesions: evidence, technique, and best practices. Expert Rev Med Devices. 2017;14(11):867-879. doi:10.1080/17434440.2017.1384695
  2. Predictors of coronary artery injury after orbital atherectomy as assessed by optical coherence tomography. Int J Cardiovasc Imaging. 2023;39(7):1367-1374. doi:10.1007/s10554-023-02837-7