• Users Online: 140
  • Print this page
  • Email this page

Table of Contents
Year : 2022  |  Volume : 19  |  Issue : 3  |  Page : 180-183

Management of calcium in coronaries: Not always as expected

Department of Cardiology, Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh

Date of Submission17-Feb-2022
Date of Decision08-Apr-2022
Date of Acceptance14-Apr-2022
Date of Web Publication10-May-2022

Correspondence Address:
F Aaysha Cader
Department of Cardiology, Ibrahim Cardiac Hospital and Research Institute, 122, Kazi Nazrul Islam Avenue, Shahbag, Dhaka 1000
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_29_22

Rights and Permissions

Percutaneous revascularization of calcified coronary lesions is being performed with increasing frequency. Particularly, in elderly patients at high bleeding risk (HBR), these procedures are rife with technical challenges, which need to be balanced against the need to adhere to the KISS (keep it simple and swift) principle, minimizing procedural complexity and duration. We report the case of a 75-year-old male with HBR, presenting with angina, in whom intravascular imaging-guided multivessel percutaneous revascularization was performed in vessels with coronary artery calcium (CAC). Rotational atherectomy was done for concentric calcification in the left anterior descending artery. CAC in a tortuous right coronary artery was tackled with a balloon-based strategy, with the help of a guide extension catheter (GEC), which itself led to long stent damage during manipulation, necessitating bailout. This case demonstrates the judicious use of available armamentarium in resource-limited settings for tackling different presentations of CAC and the appropriate selection of calcium-modifying strategy guided by intravascular imaging. We also emphasize the importance of exercising caution when using equipment such as GEC and the need for swift and appropriate bailout mechanisms of these complications.

Keywords: Complications, coronary calcium, guide extension catheter, rotational atherectomy

How to cite this article:
Cader F A, Khan SR. Management of calcium in coronaries: Not always as expected. Apollo Med 2022;19:180-3

How to cite this URL:
Cader F A, Khan SR. Management of calcium in coronaries: Not always as expected. Apollo Med [serial online] 2022 [cited 2022 Dec 5];19:180-3. Available from: https://apollomedicine.org/text.asp?2022/19/3/180/345024

  Introduction Top

Lesions of high calcium content are increasingly observed in contemporary practice. They present challenges to the interventionalist leading to suboptimal stent delivery, deployment, and expansion, necessitating adequate lesion preparation using a myriad of calcium modification strategies for stent delivery.[1],[2],[3] This is a greater challenge in certain resource-constrained environments, where the entire calcium debulking armamentarium may not be available at hand, necessitating different techniques to circumvent coronary artery calcium (CAC). The technical difficulties of such cases also lend themselves to be harbingers for increased risk of in-stent restenosis and stent thrombosis.[1],[4] Percutaneous coronary intervention (PCI) is frequently undertaken in elderly patients, in whom CAC is more predominant, and who are also at high bleeding risk (HBR), presenting a need to reduce procedural complexity while ensuring optimum stent deployment. We present the case report of successful multivessel PCI in an elderly male, with targeted bleeding avoidance strategies during PCI,[5] including intravascular imaging to guide appropriate calcium modification, keeping the procedure as swift and simple as possible.

  Case Report Top

A 75-year-old Bangladeshi male presented with Canadian Cardiovascular Society Class III-IV angina for 3–4 weeks, despite optimal medical therapy. He was diabetic, hypertensive, dyslipidemic, and mildly anemic (hemoglobin: 10.5 g/L). Electrocardiogram showed poor progression of R wave in leads V1-V4. Echocardiography was consistent with inferior wall hypokinesia and left ventricular ejection fraction of ~55%. Coronary angiography showed diffusely calcified left anterior descending (LAD), with 70%–80% proximal stenosis and 90% long-segment disease in its mid part. Principal OM had discrete 80% stenosis proximally. A dominant tortuous right coronary artery (RCA) showed 95%–99% stenosis in its mid-part with TIMI 1–2 flow [Figure 1].
Figure 1: Coronary angiography. (a) Severely diseased calcified with significant stenosis in its mid part and (b) Coronary calcium visualized angiographically. (c) 80% stenosis of proximal part of Principal OM. (d and e) Dominant calcified and angulated RCA, showing 95% stenosis in mid part with TIMI 2 flow. RCA: Right coronary artery

Click here to view

Following heart team discussion, we proceeded for PCI, as comorbidities precluded cardiac surgery. LAD was engaged with JL 3.5 6 French (F) guide. Intravascular ultrasound (IVUS) interrogation showed concentric “napkin ring” calcification of LAD [Figure 2]a. Thus, upfront rotational atherectomy was performed with three runs of rotablation with 1.5 mm burr at 160,000 rpm [Figure 2]b, followed by further lesion preparation with 2.5 mm × 15 mm noncompliant (NC) balloon (16 ATM). LAD was stented with 2.75 mm × 38 mm drug-eluting stent (DES) and postdilated with 3.0 mm × 15 mm NC balloon, with a satisfactory angiography and IVUS result [Figure 3]. The OM was then stented directly with 2.5 mm × 8 mm DES.
Figure 2: Intravascular ultrasound of LAD. (a) Baseline IVUS showing concentric “napkin ring” calcification of mid LAD. (b) IVUS after rotational atherectomy showing segment of cracked calcium. IVUS: Intravascular ultrasound, LAD: Left anterior descending

Click here to view
Figure 3: Poststenting IVUS of LAD showing good stent expansion and apposition, IVUS: Intravascular ultrasound, LAD: Left anterior descending

Click here to view

The RCA was engaged with IR 1.5 6 F guide [Figure 4]a, wired with 1.25 mm balloon support [Figure 4]b, and predilated with the same balloon [Figure 4]c. However, the vessel proved unexpectedly balloon uncrossable, as even a 2.0 mm × 8 mm balloon would not cross [Figure 4]d. As the lesion was balloon uncrossable, an IVUS catheter could not be passed at the outset. Thus, a five in six French GuideZilla Guide Extension Catheter (GEC) (Boston Scientific Corp, Natick, Massachusetts, USA) was introduced into the RCA, following which 2.0 mm × 8 and 2.5 mm × 15 mm NC balloons were able to cross for further predilatation [Figure 4]e, [Figure 4]f. Once some degree of lesion preparation was performed, subsequent IVUS interrogation showed diffuse eccentric calcification in the mid-RCA [Figure 4]g. For this reason, and also as the RCA was rather tortuous, we proceeded with a more conservative approach and did not opt to rotablate; furthermore, we wanted to keep the procedure as simple as possible in this elderly man, who would be especially prone to chronotropic incompetence, requiring an additional temporary pacing wire as well in preparation for rotablation. Thus, further lesion preparation was done with 2.5 mm × 10 mm scoring balloon inflated to 16 ATM, also negotiated through GEC [Figure 4].
Figure 4: PCI of RCA. (a) Angulated tortuous RCA with severe stenosis in mid part, (b) RCA wired with 1.25 mm × 5 mm balloon support, (c) RCA predilatation with 1.25 mm × 5 mm balloon, (d) 2.0 mm × 8 mm NC unable to cross midsegment of calcified RCA, (e) 2.0 mm × 8 mm NC balloon crossed with support of GuideZilla guide extension (arrowhead) catheter and predilated, (f) 2.5 mm × 10 mm scoring balloon crossed with support of GuideZilla guide extension (arrowhead) catheter and predilated, and (g) IVUS interrogation of RCA showing concentric calcification. PCI: Percutaneous coronary intervention, RCA: Right coronary artery, NC: Noncompliant, IVUS: Intravascular ultrasound

Click here to view

A 3.0 mm × 30 mm DES was passed through the GEC; however, the stent would not cross fully beyond the late mid-RCA and was unable to traverse the guide segment of the GEC fully, despite gentle extra manipulation [Figure 5]. We initially assumed that the distal part of the stent was not crossing owing to a calcium spicule in the RCA. However, when we brought back the assembly, including the stent into the forearm, it was apparent that the stent was unable to fully traverse the entire distal guide segment of the GEC. We, therefore, retrieved the entire system externally and found that the distal end of the stent had been deformed [Figure 5].
Figure 5: (a) 3.0 mm × 30 mm DES failed to cross late mid part of the RCA, (b) whole assembly brought to forearm, and stent failed to cross entirety of guide segment of the GEC, (c) Distal end of stent fractured and deformed, (d) Entirely new assembly taken. New 3.0 mm × 30 mm DES traverses through GuideZilla, (e) 3.0 mm × 30 mm DES crosses the angulated segment of RCA with GuideZilla support, (f) 3.0 mm × 30 mm DES deployed, and (g) Final angiographic result. DES: Drug-eluting stent, RCA: Right coronary artery, GEC: Guide extension catheter

Click here to view

We, therefore, changed the entire assembly, first ensuring that the stent was able to traverse the whole length of the GEC. A 3.0 mm × 30 mm DES was deployed at 12 ATM; however, this still required some degree of manipulation and active support. A satisfactory angiographic result with distal TIMI 3 flow was achieved [Figure 5]. A total of 145 cc of contrast were used. Total radiation dose was 3545 mGy. As this is a case of HBR and given his elderly age, dual antiplatelet therapy comprised aspirin and clopidogrel once daily. The patient remained angina-free at 2-week and 3-month follow-ups.

  Discussion Top

There are multiple challenges posed by this case, successfully navigated with available resources despite limitations. Intravascular imaging was key in the accurate detection and characterization of CAC and guided our choice of appropriate lesion-modification strategies for each vessel [1],[2],[3],[6] while minimizing procedural complexity and duration, considering this is a case of HBR.[4],[5]

Unlike in the case of the LAD, where concentric CAC necessitated upfront rotablation, there was no appreciable calcium angiographically in the RCA, and as such, we did not anticipate beforehand, the degree of calcification that was evident on IVUS. This is a testament to the utility of IVUS, as CAC distribution and thickness can be significantly underappreciated angiographically.[3],[6] However, RCA PCI was also complicated by the tortuosity of the vessel, limiting the ability to navigate equipment downstream. The GEC, an important adjunct to the calcium armamentarium, was vital for increased support and passage of balloons.[7],[8],[9] The most common indications for the use of GEC in coronary revascularization are tortuosity, calcification, angulation, and distally located lesions.[7],[8]

GEC use is not without complications, as evidenced in our case, particularly as they are used in high-risk complex anatomies, necessitating aggressive manipulation and active support. Stent fracture/stripping, because it had become deformed while crossing the collar segment of GEC, as in our case, has been previously reported in the literature.[7],[8],[9],[10] The stent deformation likely occurred due to its vigorous manipulation at the proximal junction transition of the GEC, while advancing across the angulated segment of the RCA, and can occur especially with long stents, which are less flexible.[10] Furthermore, as the stainless steel collar of the GuideZilla has limited flexibility, it may be prudent to slightly withdraw the GEC during forward advancement of stent, to avoid ending the proximal GuideZilla collar on an angulated portion of the vessel.[10] Cautious advancement is also advised in case of long stents. If resistance is encountered, it is prudent to pull the entire assembly along with unimplanted stent, as performed in our case.

While frontiers of calcium management continue to expand, their optimum use in many low- and middle-income countries is precluded by cost and nonavailability. This case has many learning points and demonstrates the judicious use of the available armamentarium for tackling CAC, the use of intravascular imaging, and the cautious bailout of complications. In addition, the case also demonstrates the importance of adequate lesion preparation which is key to successful stenting in calcified coronary arteries.

Ethical conduct of research statement

Informed consent has been obtained from the participant involved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Author Contribution

Both FAC and SRK were actively involved in the patient management. SRK was the primary operator. FAC drafted the initial manuscript, which was revised for intellectual content by SRK. Both authors have read and approved the final manuscript.

  References Top

Shah M, Najam O, Bhindi R, De Silva K. Calcium modification techniques in complex percutaneous coronary intervention. Circ Cardiovasc Interv 2021;14:e009870.  Back to cited text no. 1
De Maria GL, Scarsini R, Banning AP. Management of calcific coronary artery lesions: Is it time to change our interventional therapeutic approach? JACC Cardiovasc Interv 2019;12:1465-78.  Back to cited text no. 2
Fan LM, Tong D, Mintz GS, Mamas MA, Javed A. Breaking the deadlock of calcified coronary artery lesions: A contemporary review. Catheter Cardiovasc Interv 2021;97:108-20.  Back to cited text no. 3
Urban P, Mehran R, Colleran R, Angiolillo DJ, Byrne RA, Capodanno D, et al. Defining high bleeding risk in patients undergoing percutaneous coronary intervention: A consensus document from the Academic Research Consortium for High Bleeding Risk. Eur Heart J 2019;40:2632-53.  Back to cited text no. 4
Capodanno D, Bhatt DL, Gibson CM, James S, Kimura T, Mehran R, et al. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol 2022;19:117-32.  Back to cited text no. 5
Mintz GS, Popma JJ, Pichard AD, Kent KM, Satler LF, Chuang YC, et al. Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions. Circulation 1995;91:1959-65.  Back to cited text no. 6
Kumar P, Aggarwal P, Sinha SK, Khanra D, Razi M, Sharma AK, et al. The safety and efficacy of guidezilla catheter (mother-in-child catheter) in complex coronary interventions: An observational study. Cardiol Res 2019;10:336-44.  Back to cited text no. 7
Nasrin S, Cader FA, Haq MM, Ali ML. Angiographic analysis of trans-radial percutaneous coronary intervention cases by the backup support of guide extension catheter. Bangladesh Heart J 2018;33:54-60.  Back to cited text no. 8
Chen Y, Shah AA, Shlofmitz E, Khalid N, Musallam A, Khan JM, et al. Adverse events associated with the use of guide extension catheters during percutaneous coronary intervention: Reports from the manufacturer and user facility device experience (MAUDE) database. Cardiovasc Revasc Med 2019;20:409-12.  Back to cited text no. 9
Waggoner T, Desai H, Sanghvi K. A unique complication of the GuideZilla guide extension support catheter and the risk of stent stripping in interventional & endovascular interventions. Indian Heart J 2015;67:381-4.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded45    
    Comments [Add]    

Recommend this journal