Case 7: Severely Angulated Vein Graft PCI
- A 74-year-old male presented with angina like chest pain, mainly exertional but occasionally at rest, and relieved with SL NTG or NTG patch.
- PMH: HTN, HLD, DM, prior non-Q wave MI in 2005, PAD s/p PTAs, former smoker, obesity.
- Cardiac History: CAD s/p CABG x 2 vessel (LIMA to LAD, SVG to OM1) in 1994, and s/p multiple PCIs.
- Medications: ASA 81mg, Clopidogrel 75mg, Amlodipine 10mg, Valsartan 160mg, Metoprolol XL 50mg, Rosuvastatin 40mg, Metformin 1G.
Diagnostic coronary angiogram
Patent LIMA to LAD
90-95% stenosis located in SVG graft after severely angulated band (U shaped bend)
- With the presence of severely angulated bend prior the lesion, we anticipated that the device delivery will be difficult
- 6F AL guide with upfront use of guide extension catheter
- Buddy wire technique with a stiffer wire and workhorse wire
With the support of AL1 6F guide catheter and Guidezilla, Runthrough was used to negotiate the lesion.
- Since the lesion was not adequately expanded, we had used cutting balloon angioplasty (i.e. Wolverine 2.5/6mm) at 8 atm.
- With these challenging anatomy, we used buddy wire technique (Grand Slam and Runthrough) to deliver the equipment.
- Initial attempt was not successful to deliver the stent on Runthrough wire.
- Then, we delivered the stent on Grand Slam wire and deployed with a good result.
- In a tortuous or severely angulated vein graft intervention, use of adequate guide-catheter support, a guide extension catheter, and strong support coronary guidewire are vital to have a procedural success.
- Buddy wire technique is useful in difficult circumstances with delivering the device/stents. (i.e. Grand Slam and Runthrough)
- Coronary stent can be delivered either on soft wire or extra-support wire (Grand Slam). We delivered the stent successfully via Grand Slam in this case.