Excerpt

A 71-year-old woman was admitted to our hospital following a cardiopulmonary arrest after exercising. Coronary angiography (CAG) revealed 90% stenosis in the right coronary artery (Fig. 1A-1). Optical coherence tomography (OCT) showed that the proximal, stenotic lesion was a layered plaque suspected to be a healed coronary plaque of the fissure or dissection (Fig. 1B-b), with an approximately 1000-µm, thick, heavily calcified plaque almost circumscribing it (Fig. 1B-a). The distal stenotic lesion was a stable plaque (Fig. 1B-c). We used an orbital atherectomy system (OAS) for the proximal calcified lesions (120 s, 80,000 rpm). OCT showed sufficient debulking of the calcified plaque and plaque thinning to 500 μm (Fig. 1C-k). We expanded both the lesions with a 3.5-mm cutting balloon (Wolverine™ cutting balloon; Boston Scientific, MA, USA). Drug-coated balloon (DCB) (SeQuent Please; Nipro Corporation, Osaka, Japan) of 3.0 mm or more for de novo lesions is not allowed in Japan, but we finally used 3.5 mm-DCB for local drug delivery, because the sufficient lumen area was obtained. We achieved enough expansion comparable to that with stent implantation without coronary dissection (Fig. 1A-2). Final OCT showed significant fracture of the debulked calcified plaque (Fig. 1C-l), causing sufficient acute lumen gain (Fig. 1B-d). CAG and OCT 6 months later showed no restenosis (Fig. 1A-3). The debulked, calcified plaque area with fracture showed a late lumen loss (LLL) due to a neointima (Fig. 1B-g). However, a late lumen gain (LLG) occurred in the stenotic lesions (Fig. 1B-h, B-i).

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