Coronary calcification versus thrombus: a deceptive ambiguity revealed in the aftermath of embolisation

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @DrIHHashmi1

Case description

This is a smoker 59-year-old man with diabetes, ischemic heart disease, and a history of previous PCI with stents in the LCx, OM and LAD, who suffered from angina for two or three days. With positive cardiac biomarkers on admission, the patient was admitted on the lines of NSTEACS.

Coronary angiography revealed a short, bifurcating left main (LM) with heavily calcified LAD, and LCx with patent previously placed stents.

There was significant ostio-proximal disease in both the LAD and LCx, along with total proximal occlusion of the OM branch. Right coronary angiography demonstrated a dominant vessel with extensive calcification and significant stenotic disease involving the proximal, mid, and distal segments.

The patient was initially shifted to the ICU with a plan for multivessel PCI using rotational atherectomy.

However, post-angiography, the patient developed worsening symptoms, accompanied by significant ST-segment elevation in the anterior leads and bradycardia.

The differential diagnosis included acute thrombosis and iatrogenic dissection in the setting of heavy calcification.

The patient was urgently transferred back to the catheterisation laboratory for revascularisation. A check angiogram prompted reconsideration of the initial strategy (rotational atherectomy vs cutting balloon), as distal thrombus embolisation was noted.

A 3.0 x 6 mm cutting balloon was therefore utilised to modify the calcified lesion. This was followed by simultaneous stenting from the left main to the LAD and LCx (3.0 x 24 mm Promus Elite stents) using the simultaneous kissing stent (SKS) technique.

Post-dilatation was performed using a 4.0 mm non-compliant balloon in both the LAD and LCx, followed by final kissing balloon inflation (4.0 x 10 mm NC balloons at 12 atm), with re-establishment of TIMI 3 flow down the LAD and LCx.

The patient's hospital course was uneventful, and he was discharged after two days with a plan for staged PCI to the RCA at six weeks.

Final remarks

This case exemplifies the deceptive ambiguity of coronary pathology, often challenging initial diagnostic impressions and pre-procedural strategies.

It underscores the critical importance of integrating real-time clinical judgment with multimodality imaging to guide management.

Notably, an unexpected event—embolisation—proved pivotal in unmasking the underlying pathology and ultimately directing successful intervention.