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Case Presentation

  • A 73-year-old man present with angina like chest pain and dyspnea on exertion, concerning for unstable angina.
  • Pertinent medical history were HTN, HLD, CAD s/p CABG x 3 in 2002.
  • Medications: Aspirin 81mg , Clopidogrel 75mg, Metoprolol 50mg, Lisinopril 10mg, Atorvastatin 10mg, Furosemide 40mg, Pantoprazole 20mg
  • Coronary angiogram showed 3V CAD with patent LIMA to LAD, 95% thrombotic radial graft to D1, and occluded SVG to LCx. LVEF was 30%. Patient had PCI to OM1 and radial graft to D1.

Case Analysis and Planning

STEPS

  • Given the presence of a severely tortuous artery, the ideal wire to navigate the lesion should have a soft tip, polymer/hydrophilic cover, or a hybrid type with a hydrophilic body and hydrophobic distal tip.
  • We chose Fielder (Asahi) to navigate the tortuous anatomy along with FineCross microcatheter.
  • The guide extension catheter was slowly advanced up to mid RCA while the balloon was simultaneously deflated.
  • (Balloon assisted suction technique)

Wiring Technique

  • Then, three DES were placed in proximal, and mid RCA with an excellent result.

Learning Points

  • The optimal wire for tortuous artery should have a soft tip, polymer/hydrophilic cover and we had used Fielder wire in this case.
  • A guide extension catheter with a stiff wire (i.e. Grandslam) can be used for a better support and device delivery.
  • Another option would be the use of buddy wire technique to deliver the devices in difficult situation. (i.e. Fielder and Runthrough or two Fielder wires)
  • In case of difficulty in advancing guide extension catheter, the guideliner suction technique is useful to advance the catheter.

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)              
681215202530
MINI TREK (CTO INDICATED)1.271.2
1.561.5
2.172✓*✓*
TREK2.372.25
2.672.5
2.912.75
3.113
3.53.25
3.73.5
3.943.75
4.324
4.864.5
5.365
*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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