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Case 25: Angulated LAD Intervention Using Angulated Catheter

Case Presentation

  • A 65-year-old man presented with a new onset CCS class II angina. CTA coronary showed high calcium score of 2684 with 2 V CAD (RCA and LAD).
  • PMH: Non insulin dependent DM, Hyperlipidemia
  • Medications: Aspirin, Rosuvastatin, Metoprolol, Metformin
  • Angiogram showed severely calcified 2 V CAD: 90% mid RCA, and multiple calcified severely angulated proximal and mid LAD/Diagonal bifurcation lesions.
  • Patient underwent successful PCI of RCA and here for staged PCI of LAD with the use of angulated catheter.

Case Description

Pre-Angiogram

PCI Strategy

  • 6F guide catheter
  • Runthrough wire with an angulated catheter to navigate the angulated LAD lesion
  • Lesion modification with cutting balloon angioplasty, followed by stent placement
  • Provision stenting technique

PCI Strategy

STEPS

  • First, navigate Runthrough wire into the diagonal branch.
  • Followed by Venture catheter advancement up to the LAD-Diagonal bifurcation.
  • Then, pull the wire back while maintaining the tip of Venture at the level of bifurcation.
  • Perform clockwise rotation of Venture to create 90-degree bend, followed by navigating Runthrough wire into the angulated LAD lesion.

STEPS

  • Then, the lesion modification was performed by using 3.5/6 mm Wolverine balloon.
  • Two DES were placed in proximal LAD (Promus 4/28 mm) and mid LAD (Promus 3/38 mm) with an excellent result.

Final Angiogram

Learning Points

  • Case planning is paramount in the angulated lesion intervention.
  • Wiring technique in angulated lesions is complex and often require adjunct device to negotiate the lesions.
  • Angulated catheters such as SuperCross, Venture, and Swift Ninja could help the guidewire to advance through the lesions in challenging and complex coronary artery disease interventions.

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