Case Title

Angioplasty & Stenting in tortuous vessels

Case History

This 68 year old gentlemen underwent CABG 5 yrs ago, he underwent angiography for his increasing angina for the past 3 weeks.

Findings revealed right coronary artery is heavily calcified proximally. There is about 50% tubular narrowing in RCA 2 cms away from its origin. Earlier he had received vein graft to his PDA (side to side) and the same graft was carried toward sequentially to his OM branch. The sequential portion of the graft from PDA to OM branch is visualized here. This portion of the graft shows 90% stenosis ¾th cm proximal to its insertion. Right coronary artery injection in PA cranial view confirms the findings of cine 1 but shows marked tortousity with omega band in proximal PDA. Internal mammary injection anastomoses to mid segment LAD. IM has grown to about 3mm in size. In this view (RAO 29o cranial 17o) IM shows marked tortousity there is about 70-80% narrowing in LAD just distal to anastomoses of LIMA to LAD. 90o Lateral confirms the findings. Plan: It was decided to address LAD lesion first. Approach: Right femoral Hard wares: LIMA Guide, Choice PT Extra support wire Balloon: 2.5/15mm Maverick 2 Stent: 2.5/12 Taxus Shows LIMA catheter cannulated ostium of LIMA choice PT guide wire is shown advanced up to 1st major tortousity Shows successful advancement of wire right up to the bottom of LAD. Please Note: Direct stenting of LAD lesion through LIMA. Marked difficulties experienced in negotiating acute bend in LIMA its mid segment. Shows positioning of the stent at the site of the lesion Shows excellent outcome of the stent placement. Shows final results. Addressing the venous graft lesion prior to its insertion into OM branch. Through Suakins Right coronary catheter, choice PT Extra support wire is advanced right up to the lesion. Considerable technical difficulties were experienced while negotiating omega curve at the function of RCA & PDA. Note tip of the wire into one of the circumflex branches via the venous graft. 2.5/12mm maverick 2 balloon is seen across the session Shows the waste in the balloon due to session Lesion opens up at 18 atm pressure. Shows opening up of the lesion.

Comments

Please Note: Much more heavier & opacification of the OM branch after opening the right stenosis in the distal graft.

Here are 2 examples of dealing with torturous vessels. LIMA is a very sensitive artery excessive manipulation could lead to spasm of the artery. In negotiating LIMA tortousity I have found choice PT wire to be the best because of its hydrophilic coating wire glides through tortousity quite smoothly & easily. In this case stent had to be negotiated through torturous curves. This choice PT extra support wire allowed not only negotiations of stents through curvatures but even direct stenting.

RCA posed different problems:

1. Vessel was markedly torturous
2. The lesion was very distal & extremely tight and that too in the venous graft
3. The entire proximal segments of the artery was heavily calcified & rigid. Moreover there was non-significant atheromatous plaque with 40% stenosis proximally and this completely discouraged deep rooting of the catheter if needed for the backup and for crossing the balloon across the very tight lesion.

Maverick balloon has excellent profile & is very slippery making negotiations through very tight and distal lesions easy. Unfortunately in this case stent could not be delivered due to heavy calcification proximally in the RCA. This could expose him to increased risk of restenosis.

Courtesy

Dr. A.B. Mehta
Director Of Cardiology,
Jaslok Hospital,
Mumbai, India.

Website: http://www.drabmehta.com
Email: drabmehta@cardiovalens.com