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Case 8: Aneurysmal RCA Disease

Case Presentation

  • A 74-year-old male presented with left sided chest pain at rest and dyspnea on exertion.
  • Medical history: HTN, HLD, CAD s/p multiple PCIs and CABG 1999.
  • Medications: ASA 81mg, Losartan 50mg, Metoprolol XL 100mg, Isosorbide Mononitrate 30m, Atorvastatin 40mg
  • Coronary angiogram revealed 3V CAD : mid LAD-CTO, Ramus 80-90%, and aneurysmal RCA with 90% stenosis (just distal to aneurysmal segment) and patent LIMA to LAD.
  • Planned for aneurysmal RCA intervention.



PCI Strategy

  • Given the presence of aneurysm prior to the lesion, we anticipated the difficult wiring through the aneurysmal segment of RCA.
  • AL 0.75 6F guide catheter
  • To negotiate through an aneurysm, planned to use a wire with hydrophobic coated and a stiffer tip (better tactile feedback and excellent torqueability), along with a microcatheter for additional support.
  • Our wire choice – Fielder and FineCross > Gaia > MiracleBros and would consider angulated microcatheter as needed.
  • With AL 0.75 6F guide catheter,  Fielder and FineCross microcatheter was used to navigate the lesion but it was unsuccessful to exit the aneurysmal segment.
  • Then, we exchanged to Gaia second (Asahi), followed by Gaia third (Asahi) to negotiate the artery without success.
  • Finally, we opted to use an angulated microcatheter (Supercross 90) and Fielder, then able to navigate through the aneurysmal segment.
  • A Guidezilla 6F was advanced for a better support.
  • Predilatation was done by using non-compliant balloon 3.5/12mm.
  • With the support of 6F AL 0.75 and Guidezilla, one DES (4/16mm) was implanted in dRCA without any difficulty.

Final Angiogram

Learning Points

  • Use of microcatheter is important as much as guidewire selection in a challenging case.
  • The presence of wire’s flexibility and excellent trackability is essential to tackle these challenging anatomy.
  • The challenging part to wire an aneurysm is that the wire tends to coil up inside the aneurysm and often requires a stiffer wire with hydrophobic coated tip (i.e. MiracleBros, Gaia) to negotiate through the exit of the aneurysmal segment.
  • Angulated microcatheter (i.e. Supercross, Venture) provides a better support and facilitates in wiring through a severely angulated side branch and aneurysmal lesion.

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)
*Only available as RX, not as OTW. Other sizes available in both versions.
Retrieved on April 07 2022 from Abbott product ordering information. Please look at the company's files for the latest available data on device configurations and avilability in your area.

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