Intravascular ultrasound and ultrasonic flow ratio-guided zero-contrast rotational atherectomy for calcified coronary lesions

A 63-year-old man with hypertension and hyperlipidaemia presented with effort angina 10 years ago. Immediately after administration of iodinated contrast, he developed haemodynamic collapse and cardiac arrest, which required brief cardiopulmonary resuscitation. A reattempt was undertaken 3 months later after he was pre-medicated for a contrast allergy. However, after challenge with 30 mL contrast and two stents being implanted in the anterior descending artery, he experienced severe cardiopulmonary collapse again. After prompt treatment with epinephrine, dopamine, and intra-aortic balloon pump support, he achieved a complete recovery without any symptoms for 10 years. However, he suffered from recurrent exertional angina despite optimal antianginal medications starting in September 2021. Admission electrocardiogram revealed ST depression in Leads II, III, and aVF and a Troponin I level of 0.370 ng/mL. Given the severity of the patient’s reaction to the contrast agent, intravascular ultrasound (IVUS) (OptiCross, Boston Scientific, MA, USA) and ultrasonic flow ratio (UFR) (IVUS Plus, Pulse Medical Imaging Technology, Shanghai, China)-guided zero-contrast percutaneous coronary intervention was indicated. Previous coronary angiographic films were used as a roadmap for procedural planning (Panels A and B, Supplementary material online, Videos S1 and S2). All three major coronaries were assessed by IVUS, and UFR was calculated based on IVUS images. Accordingly, the right coronary artery (RCA) and left circumflex artery (LCX) were physiologically positive (UFR = 0.79 and 0.81, respectively) (Panels C and D). Intravascular ultrasound images showed diffuse calcification in the proximal LCX and mid-RCA with a calcification arc of more than 270° (Supplementary material online, Videos S3 and S4). Rotational atherectomy using 1.75 mm burr @160 000 rpm was performed for the RCA lesion (Panel E, Supplementary material online, Video S5). Post-atherectomy, the mid-RCA lesion was dilated with a 3.0 × 12 mm noncompliant (NC) balloon. Mid to proximal RCA stenting was done with 3.0 × 26 mm and 3.5 × 28 mm drug-eluting stents. After post-dilatation with a 3.5 × 15 mm NC balloon, full expansion with a perfect UFR (0.97) was achieved (Panel G, Supplementary material online, Video S6). Rotational atherectomy using 1.75 mm burr @160 000 rpm was performed for the LCX lesion (Panel F, Supplementary material online, Video S7). Then, the proximal LCX lesion was dilated, and a 3.0 × 28 mm drug-eluting stent was implanted. After post-dilatation with a 3.0 × 15 mm NC balloon, full expansion with a perfect UFR (0.98) was achieved (Panel H, Supplementary material online, Video S8). The entire procedure was completed with 0 mL contrast. The patient denied any ischemic symptoms, and electrocardiogram exercise test was normal at 6-month follow-up.