Case 1: Tortuous Artery

Case Presentation

A 73-year-old man present with angina like chest pain and dyspnea on exertion, concerning for unstable angina.
Pertinent medical history were HTN, HLD, CAD s/p CABG x 3 in 2002.
Medications: Aspirin 81mg , Clopidogrel 75mg, Metoprolol 50mg, Lisinopril 10mg, Atorvastatin 10mg, Furosemide 40mg, Pantoprazole 20mg
Coronary angiogram showed 3V CAD with patent LIMA to LAD, 95% thrombotic radial graft to D1, and occluded SVG to LCx. LVEF was 30%. Patient had PCI to OM1 and radial graft to D1.

Coronary angiogram showed multiple lesions in severely angulated and tortuous RCA.
Planned to undergo PCI to multiple angulated lesions of tortuous RCA with LV assist device.

Given the presence of a severely tortuous artery, the ideal wire to navigate the lesion should have a soft tip, polymer/hydrophilic cover, or a hybrid type with a hydrophilic body and hydrophobic distal tip.
We chose Fielder (Asahi) to navigate the tortuous anatomy along with FineCross microcatheter.

Once Fielder wire reached to the distal part of RCA, FineCross catheter was advanced over the Fielder wire.
With anticipation of requiring good support for PCI, Grandslam wire (300 cm) was exchanged via FineCross catheter.
Then guide extension catheter was advanced over the Grandslam.

The guide extension catheter was slowly advanced up to mid RCA while the balloon was simultaneously deflated.
(Balloon assisted suction technique)

The optimal wire for tortuous artery should have a soft tip, polymer/hydrophilic cover and we had used Fielder wire in this case.
A guide extension catheter with a stiff wire (i.e. Grandslam) can be used for a better support and device delivery.
Another option would be the use of buddy wire technique to deliver the devices in difficult situation. (i.e. Fielder and Runthrough or two Fielder wires)
In case of difficulty in advancing guide extension catheter, the guideliner suction technique is useful to advance the catheter.