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.
