Abstract

Clinical history: 69 year old gentleman with hypertension, diabetes and dyslipidemia. Admitted on March 2022 for anterior STEMI. Angiography showed tight tandem stenosis on mid-LAD with TIMI 2 distal flow.Treatment strategy: radial access, predilatation, stent implantation. But no predilatation balloon was going to cross second, severely calcified lesion, neither with anchoring balloon on first diagonal.Treatment changing strategy: shift to rotational atherectomy procedure. Microcatheter not able to cross lesion as well, so RotaWire was advanced directly through MC. Rotational atherectomy performed with 1.5 mm burr with risk of burr entrapment and no flow. Transient heamodynamic instability treated with amine support and IABP.PPCI completed with 2 DES implantation with good angiographic result, nearly TIMI 3 distal flow and good ST segment resolution.Take home message: STEMI is a challenging situation especially anterior AMI when heamodynamic impairment is more likely to occur. Leaving MC as close as possible to calcified lesion allowed easier Rota Wire manipulation in order to obtain direct distal LAD wiring through tortuosity and calcified lesion. Rotational atherectomy is off label in STEMI setting but was the only available option. Other ventricular assistance devices such as Impella may be better than IABP in this setting, if available in cath lab.