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Case 26: Severely Angulated and Tortuous RCA Intervention

Case Presentation

  • An 88-year-old man presented with a new onset CCS class III angina. Found to have NSTEMI with troponin level of 2.41. Cath @ OSH showed severe and tortuous disease in RCA and was not able to intervene due to difficulty in wiring along with devices delivery. Then, patient was transferred to tertiary center for complex coronary intervention.
  • PMH: HTN, Hyperlipidemia, COPD, CVA with left hemiparesis
  • Medications: Aspirin, Clopidogrel, Metoprolol tartrate, amlodipine, Atorvastatin

Pre-Angiogram

PCI Strategy

  • AL 0.75 with SH
  • Fielder and FineCross microcatheter
  • Given the presence of severely angulated and tortuous lesion, the wire choice should have a soft tip, polymer/hydrophilic cover, moderate support
  • Plan to escalate the wire as needed; MiracleBros 3, Gaia Next 3, Pilot 200, Fighter
  • Predilation and stenting

STEPS

  • We used Fielder and FineCross microcatheter.
  • As Fielder wire was not able to advance, the wire escalation was performed using MiracleBros 3, Gaia Next 3, and Pilot 200.
  • Finally, we were able to negotiate the lesion by using Fighter wire (tapering tip with hydrophilic coating).

Wiring Technique

Final Angiogram

  • The predilation in mid and distal RCA was performed by using TREK NC 2.5/20, followed by the placement two DESs (Promus Elite 2.75/32 and Promus Elite 2.5/38).

Learning Points

  • With the presence of severely angulated and tortuous lesion, the wire should possess a soft tip, polymer/hydrophilic cover, and moderate support.
  • First, we had used a higher tip load with or without hydrophobic tip as well as hydrophilic coating such as MiracleBros 3, Gaia Next 3, and Pilot 200.
  • As these wires failed, we had switched to tapered tip, polymer/hydrophilic cover with moderate support wire such as Fighter wire which was able to negotiate the lesion successfully.
  • Hence, knowing all the wire properties as well as when to switch the wire is paramount to have a successful PCI.

Left Main DK Crush Video ID