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Case 2: Ectatic And Severely Tortuous Long ISR of RCA

Case Presentation

  • A 62-year-old man presented with angina like chest pain and stress MPI showed moderate size of inferior and infero-lateral ischemia.
  • Cardiac angiogram revealed 2V CAD with 80% long segmental in-stent restenosis after severe proximal tortuosity of ectatic mid RCA and 70% discrete lesion in LCx-OM1. LVEF was 48%.
  • Medical History: HTN, NIDDM, HLD, prior MI, Ex smoker, COPD on inhalers, Morbid Obesity
  • Coronary angiogram showed ectatic, severely long lesion in mid RCA.
  • The initial attempt of PCI to RCA in another institution was unsuccessful as the stent could not delivered despite the use of a Guideliner.

PCI Strategy

  • With this challenging anatomy, we planned to start the procedure with long femoral sheath (45 cm) and 7F Amplatz Left 0.75 guide catheter.
  • A Runthrough wire with upfront guide extension catheter (i.e. Guidezilla) were used.

Case Planning

  • The Runthrough wire was advanced to the distal segment but inadvertently went to under the previous stent strut due to under-expanded stent in mid-RCA.
  • The operator pulled the wire back and advanced carefully inside the stent.
  • Serial balloon dilatation were performed.
  • Guidezilla was slowly advanced simultaneously while deflating the balloon which was located at the tip of catheter.
  • However, we were not able to deliver the stent.
  • Then, a buddy wire method was used by placing Fielder wire along with Runthrough and Guidezilla.

Buddy Wire Technique

Stent Delivery

  • One DES (Synergy 4/38mm) was advanced over the Fielder wire which has excellent trackability, lubricity, and flexibility, then deployed in mid RCA with good result.

Learning Points

  • Upfront use of the guide extension catheter (i.e. Guidezilla) with a workhorse wire should be considered in a tortuous vessel.
  • Buddy wire technique is another option to tackle this type of challenging anatomy. (i.e. Fielder and Runthrough).
  • Among various guide extension catheters, Guidezilla has larger inner diameter (1.45 vs 1.42  mm) and smaller outer diameter (1.68 vs 1.7 mm) compared to Guideliner catheter.
  • Moreover, Guidezilla has a new hydrophilic coating; therefore providing a better device deliverability.

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)              
681215202530
MINI TREK (CTO INDICATED)1.271.2
1.561.5
2.172✓*✓*
TREK2.372.25
2.672.5
2.912.75
3.113
3.53.25
3.73.5
3.943.75
4.324
4.864.5
5.365
*Only available as RX, not as OTW. Other sizes available in both versions.
Retrieved on April 07 2022 from Abbott product ordering information. Please look at the company's files for the latest available data on device configurations and avilability in your area.

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