"Rocky" right coronary artery

Consult this Twitter case concerning a 74-year-old man with chest pain and a positive stress test with calcified coronary lesions.

This case was originally published on Twitter by @jorgeachv via #CardioTwitterCase

Clinical presentation

We present a 74-year-old man, with history of hypertension, dyslipidaemia, and former smoker. Clinical history of chest pain with moderate exercise.
Echocardiogram showed mild hypokinesia on LAD territory with slight reduction of the left ventricular systolic function at rest. A stress test was performed, a diffuse ST depression was observed in peripheral and precordial leads.

Case Management

The patient was taken to the Cath lab and the angiogram showed an extensive calcified lesion on LAD, as well as an RCA calcified lesion (Figure 1). Initially, it was decided to treat the LAD, and it was necessary to use Rotablator to facilitate predilatation and two DES stents were implanted.

The patient was admitted to the CCU and was taken back to the cath lab 72 hours later. The RCA lesion was severely calcified, a baseline OCT study showed highly attenuating tissue without clear borders (Figure 2, Video 1).

Our initial diagnostic was calcium nodules because there was a bright protruding mass with an irregular surface causing major dorsal shadowing on OCT mimicking the appearance of lipid or red thrombus (Video 1 and 2).

It was necessary to use Rotablator, then a DES stent was implanted at 18 atm with postdilation with non-compliant balloons to achieve a good result and expansion. Final angiography showed TIMI 3 flow, no dissections, and more than 80% of expansion (Figure 1).

The patient was followed in the CCU and discharged 4 days later with optimal medical treatment.
This case shows the importance of imaging studies like OCT and technology as the Rotablator for cases where it is difficult to get adequate predilatation and stent implantation, especially in fibro-calcific lesions.

Original tweet and Twitter discussion

Beautiful OCT images #OCTimaging. what do you think about the dx? #imagingfirst@AdrianLostalo@lorenzo2509@cardiojsl@DrNataliaP@OjedaOjeda18@lamelaspablo@sbrugaletta@mmamas1973@gutierrezjaikel@lydiarocap@MatiasJArevalo@evandrofilhobr@drbijagua@JChrisBarahonapic.twitter.com/FJP7F8Nihs

— Jorge Andres Chavarria Viquez (@jorgeachv) December 23, 2019