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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.

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