Rotational Atherectomy of a Lesion in Which Stent Expansion Was Limited by Severe Calcification

receiving at the time of admission, consisting of atenolol, atorvastatin and aspirin, clopidogrel, and intravenous infusion of nitroglycerin was initiated and cardiac catheterization was performed. The left ventricle, which was hypertrophic and presented moderate hypokinesia of the apical region, preserved an ejection fraction of 63%. The bifurcation of the left main cononary artery presented a stenosis of 40% and subtotal occlusion of the ostium of the circumflex artery. This vessel, which was occluded distally, was being supplied via inadequate collateral circulation branching from the right coronary artery, which presented severe stenosis of the middle segment. All these lesions were successfully treated by means of stent placement. The left anterior descending coronary artery (Figure, A), possibly the culprit vessel, presented an extensive severe, calcified stenosis of the middle segment. After predilatation using a 2.5×25-mm Maverick balloon, a 2.75×24-mm Driver stent was implanted; however, a portion of the distal third did not expand completely, presenting a diabolo-like image (Figure, B). An attempt to post dilate using a 3.0×13-mm Powersail balloon inflated to a pressure of 25 atmospheres failed (Figure, C), and therefore rotational atherectomy using a 1.75-mm oliveshaped burr (Figure, D) was carried out. Afterwards, post dilatation resulted effective, and a 3.0×12-mm Taxus pharmacoactive stent was deployed into the previously implanted stent (Figure, E). The final angiographic result was excellent (Figure, F) and there were no adverse events. The postoperative course was satisfactory and the patient, when discharged from the hospital 48 hours later, was asymptomatic. At 5 months, coronary angiography revealed the absence of restenosis in the Taxus stent. The efficacy of rotational atherectomy in situations of incomplete expansion of stents implanted in severely calcified lesions has been demonstrated in three previously reported cases in which there were no problems associated with the erosion of the metal.1,2 The success may be attributed to the ablation of the stent rings and the calcium that protruded through them, resulting in the thinning of the wall. Although Letters to the Editor