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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.

Case Analysis and Planning

STEPS

  • 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)

Wiring Technique

  • Then, three DES were placed in proximal, and mid RCA with an excellent result.

Learning Points

  • 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.

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