Rotablation in presence of thrombus and dissection: a case report

A team of cardiologists led by Dr. Saibal Mukhopadhay at GB Pant hospital, New Delhi performed Rotablation in a case of coronary dissection and thrombus which are considered contraindications as a bailout strategy.

A 60-year-old gentleman, a known case of stable angina on medical therapy for 5 months presented with rest angina, ST depressions in anterior leads and elevated Trop T levels. Coronary angiogram revealed critical calcific lesion in proximal LAD and accordingly angioplasty was planned. As the lesion was non-dilatable with non complaint and cutting balloons, plaque modification with rotablation by using 1.5 burr was done. A type B dissection was noted in proximal LAD and lesion was still non dilatable with balloon. Stent was deployed from mid to distal LAD with residual stenosis along with non flow limiting Type A dissection in proximal LAD. Staged PTCA to proximal LAD was planned the next day with 1.75 burr which was not available on same day. As patient was aymptomatic it was decided to allow dissection to heal and angioplasty to defer for next 4 weeks.

On the 9th day after angioplasty patient developed complete thrombotic occlusion of proximal LAD at the site of dissection. Rotablation, in presence of both thrombus and dissection, was successfully done adopting some precautions as an emergency bailout procedure. Patient was discharged in a stable state after 72 hours following procedure.

Rotablation is usually contraindicated in presence of dissection and thrombus. Rotablation in presence of dissection can lead to entrapment of the flap in the rotating burr leading to progression of dissection distally or sometimes there can be subintimal tracking of burr leading to perforation. In the presence of thrombus platelet activation and aggregation by the spinning burr or distal embolization of the thrombotic material promoting slow or no flow can occur.