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.
The case can be reviewed at https://ccclivecases.org/complex-coronary/december-2018-ccc-live-case
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.
