Case Title

Complex angioplasty in tortuous vessels

This 59 yrs old gentleman had undergone CABG in 1996. He has recently developed class 2 angina. History of an AMI in 1987. Lately increase in the frequency of angina in the last 3 months. 2d ECHO –Hypokinesia of IVS. LVEF is 30%.

Patient received LIMA to Lad, SVG to PDA and SVG to OM1.

The native angiography showed following salient features:

Left main is normal; LAD shows 50% stenosis in its mid segment. The mid and distal lad shows 2 distal runoff with evidence of competitive flow to the IMA graft. Circumflex is moderate in size, non dominant vessel. OM1 has 80% osteal stenosis. RCA moderate sized vessel. The only critical lesion is in distal RCA of 99% with TIMI –1 antigrade flow.

To dialate the LAD distal to the graft anastomosis site.

Will be IMA conduit.

To dialate ostium of OM1.

The guide catheter sitting in the ostium of IMA. LIMA takes a very torturous course showing at least 2 omega curves proximally. Lateral oblique view injection shows the whole IMA is markedly torturous. Note : Severe stenosis in mid LAD just distal to the site of anastomosis. Shows LIMA guide catheter 6F sitting at the mouth of IMA. Choice PT extra support wire is being advanced, because of its hydrophilic coating wire is capable of taking severe and acute bends quite easily. Shows the wire movement. The wire is advanced further successfully negotiating through the difficult curves. Note that the wire has successfully traversed through the hairpin bend in the LIMA Conduit. At this point balloon support was taken using 2.0x 9 mm maverick balloons. With this the wire could be parked way distal into the LAD. Lesion addressed with 2.0x 9mm balloon and was opened up at 5 ATM twice. 2.25x15 mm stent was advanced. Shows stent gliding over choice PT extra support wire and even negotiating through hairpin bend quite smoothly and easily. Notice number of pseudo lesions all throughout the length of LIMA graft due to according effect of the stiff wire traversing through the graft. Shows the stent deployed at 14 ATM at 13 secs. Note good final results with 0% residual stenosis. Shows the final results shown in PA cranial view with excellent outcome. Notice that after the removal of wire all the pseudo lesions have disappeared.

Usually LIMA grafts are very torturous. They require extremely traceable hydrophilic wires with excellent support. In my opinion choice PT extra support wire is excellent for this kind of anatomy. Very often the guide catheter needed should be short in length because stent balloon shaft length is often taken away by lengthy torturous LIMA graft. It’s not uncommon that a balloon or a stent may not be able to reach the lesion site. Another great advantage of hydrophilic wire is that its smooth & slippery surface allows the stent to glide over the wire very easily, like in this case. Subsequently steps of balloon inflation & stent deployment are routine and easy. Use of choice PT extra support wire requires fair amount of experience & care. Casual use of this wire may lead to subintimal passage without the operator even realising it.

Courtesy

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

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