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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.

Left Main DK Crush Video ID