Case presentation

A healthy and active 83-year-old woman without prior cardiac history presented with 1 week of intermittent chest pain, culminating in a prolonged episode of severe rest pain prompting hospital admission. In the emergency department, her initial electrocardiogram showed inferior T-wave changes, and she quickly became pain-free with nitrates, aspirin, a beta blocker, and unfractionated heparin. Subsequent serial troponin values peaked at 3.9 ng/mL. She was diagnosed with a non-ST segment elevation myocardial infarction. Her past medical history is notable only for hypertension, hyperlipidemia, and degenerative joint disease, and she lives independently. Her physical examination was unremarkable and her laboratory studies were notable only for a serum creatinine of 1.3 mg/dL. She was referred for cardiac catheterization.

Cardiac catheterization

Coronary angiography found no significant obstructive disease in the left coronary artery (Figure 10-1) but a severe ostial stenosis of the right coronary artery, with extensive calcification (Figure 10-2 and Video 10-1). Based on the angiogram, her physician decided to proceed with a percutaneous approach and, anticipating great difficulty because of the ostial location and the degree of calcification observed, the operator planned to debulk the lesion with rotational atherectomy.

FIGURE 10-1 This is the left coronary angiogram; there were no significant obstructive lesions noted.

FIGURE 10-2 The ostium of the right coronary artery was severely narrowed with heavy calcification noted around the ostium (arrow).

Femoral venous access was obtained and a temporary pacemaker wire positioned in the right ventricular apex. The operator then engaged an 8 French right Judkins guide catheter with side holes and administered eptifibatide as a double bolus plus infusion along with unfractionated heparin to achieve an activated clotting time (ACT) greater than 200 seconds. A floppy-tipped rotational atherectomy guidewire was positioned distally in the right coronary artery. Rotational atherectomy was accomplished first with a 1.5 mm burr, followed by a 2.0 mm burr. The angiographic result after rotational atherectomy is shown in Figure 10-3 and Video 10-2. The operator removed the rotational atherectomy guidewire and positioned a conventional 0.014 inch floppy-tipped guidewire distally in the right coronary artery. The lesion was dilated with a 3.0 mm diameter by 20 mm long compliant balloon and a 3.5 mm diameter by 23 mm long sirolimus-eluting stent positioned to cover the ostium (Figure 10-4 and Video 10-3) and postdilated with a 4.0 mm diameter by 9 mm long noncompliant balloon to high pressures. The final angiographic images satisfied the operator, although mild narrowing remained at the ostium (Figure 10-5 and Video 10-4); intravascular ultrasound was not performed and the procedure was terminated.

FIGURE 10-3 This is the angiographic result after rotational atherectomy with a 2.0 mm burr.

FIGURE 10-4 This figure demonstrates the position of the stent relative to the right coronary ostium.

FIGURE 10-5 Final angiographic results after stenting the right coronary ostial lesion.

Postprocedural course

The pacing electrode was withdrawn and the femoral sheaths removed using manual pressure when the ACT fell below 180 seconds. After an uncomplicated overnight stay, she was discharged the next morning on clopidogrel, aspirin, atenolol, atorvastatin, and lisinopril.

She remained symptom-free for 5 months, and then developed recurrent severe chest pain similar to her initial symptoms. She was again admitted to the hospital, but this time, serial troponins were negative. Repeat cardiac catheterization revealed severe, in-stent restenosis of the ostium of the right coronary artery (Figure 10-6