Yaygın Kalsifik LAD Lezyonu Orbital Aterektomi ve IVUS Eşliğinde Tedavi Edilmesi
Özet
Kalsifik koroner lezyonlar perkütan koroner girişimin (PKG) en zorlu lezyon tiplerinden biridir. Yetersiz lezyon hazırlığı , stent underekspansiyonu, stent malpozisyonu ve buna bağlı istenmeyen klinik sonuçlarla ilişkilidir. Bu nedenle intravasküler ultrasonografi (IVUS) ve optik koherens tomografi (OCT), lezyon morfolojisinin değerlendirilmesi, uygun tedavi stratejisinin belirlenmesi ve stent optimizasyonunun sağlanmasında temel görüntüleme yöntemleridir. Özellikle yaygın ve ileri derecede kalsifik lezyonlarda, yeterli kalsiyum modifikasyonu sağlamak amacıyla aterektomi sistemleri tercih edilmektedir. Bu olgu sunumunda, göğüs ağrısı ile başvuran 77 yaşındaki kadın hastaya non-ST elevasyonlu miyokard infarktüsü (NSTEMI) tanısıyla koroner anjiyografi yapıldı. Anjiyografide ostealden orta segmente kadar uzanan yaygın ve ileri derecede kalsifik sol ön inen arter (LAD) lezyonu saptanması üzerine IVUS ile lezyon karakterizasyonu gerçekleştirildi. Yaygın, konsantrik ve derin kalsifikasyon nedeniyle optimal lezyon hazırlığı ve yeterli stent ekspansiyonu sağlamak amacıyla orbital aterektomi uygulandı. Ardından perkütan koroner girişim başarıyla tamamlandı ve hastanın üç aylık klinik takibinde herhangi bir kardiyovasküler semptom izlenmedi.
Calcified coronary lesions represent one of the most challenging lesion subsets in percutaneous coronary intervention (PCI). Inadequate lesion preparation is associated with stent underexpansion, stent malapposition, and adverse clinical outcomes. Therefore, intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are essential imaging modalities for lesion characterization, procedural planning, and stent optimization. Atherectomy devices are preferred in diffuse and severely calcified lesions to achieve adequate calcium modification before stent implantation. We present the case of a 77-year-old woman who was admitted with chest pain and diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI). Coronary angiography revealed a diffuse, severely calcified lesion extending from the ostial to the mid-left anterior descending artery (LAD). IVUS was performed for detailed lesion characterization, demonstrating extensive concentric and deep calcification. Orbital atherectomy was selected to achieve optimal lesion preparation and facilitate adequate stent expansion. Subsequently, PCI was successfully completed. At the three-month follow-up, the patient remained free of cardiovascular symptoms. This case highlights that IVUS-guided orbital atherectomy is a safe and effective treatment strategy for achieving successful revascularization in patients with complex, heavily calcified coronary lesions.
Referanslar
Caiazzo G, Di Mario C, Kedhi E, De Luca G. Current Management of Highly Calcified Coronary Lesions: An Overview of the Current Status. J Clin Med. 2023 Jul 23;12(14):4844. doi: 10.3390/jcm12144844. PMID: 37510959; PMCID: PMC10381772.
Kałmucki P, Skonieczna P, Basık A, Siminiak T. Management of Calcified Coronary Lesions-A Review of Plaque Modification Methods. J Clin Med. 2025 Dec 3;14(23):8566. doi: 10.3390/jcm14238566. PMID: 41375870; PMCID: PMC12693342.
Riley, R. F., Patel, M. P., Abbott, J. D., Bangalore, S., Brilakis, E. S., Croce et al (2024). SCAI Expert Consensus Statement on the Management of Calcified Coronary Lesions. Journal of the Society for Cardiovascular Angiography & Interventions, 3(2), 101259. https://doi.org/10.1016/j.jscai.2023.101259
Shin, D., Malik, S., Singh, M., Dakroub, A., Sakai, K., Jeremias, A., et al (2025). Intracoronary Imaging for Calcium Modification: Intravascular Ultrasound and Optical Coherence Tomography. Interventional cardiology (London, England), 20, e27. https://doi.org/10.15420/icr.2024.01
Viana, S. M., & Zhang, D. M. (2024). Intravascular Ultrasound Guiding Percutaneous Coronary Interventions in Complex Higher Risk-Indicated Patients (CHIPs): Insight from Clinical Evidence. Revireyse in cardiovascular medicine, 25(12), 443. https://doi.org/10.31083/j.rcm2512443
Senguttavan, N. B., Ramakumar, V., Naik, N., Kini, A., & Sharma, S. K. (2025). Contemporary management of calcified coronary artery disease. Indian heart journal, 77(6), 405–415. https://doi.org/10.1016/j.ihj.2025.09.007
Shlofmitz, E., Martinsen, B. J., Lee, M., Rao, S. V., Généreux, P., Higgins, et al (2017). Orbital atherectomy for the treatment of severely calcified coronary lesions: evidence, technique, and best practices. Expert review of medical devices, 14(11), 867–879. https://doi.org/10.1080/17434440.2017.1384695
Visinoni, Z. M., Jurewitz, D. L., Kereiakes, D. J., Shlofmitz, R., Shlofmitz, E., Ali, Z., et al (2024). Coronary intravascular lithotripsy for severe coronary artery calcification: The Disrupt CAD I-IV trials. Cardiovascular revascularization medicine : including molecular interventions, 65, 81–87. https://doi.org/10.1016/j.carrev.2024.03.001
