Slides

Antegrade approach to pRCA ISR CTO

- Operator : Seung-Jung Park

Antegrade approach to pRCA ISR CTO
- Operator: Seung-Jung Park, MD
Case Presentation
A 54 year-old man was admitted for evaluation of abnormal stress test results. Two years ago, he had experienced an inferior wall STEMI, and had been implanted with bare metal stent at proximal RCA. One year ago, he underwent balloon angioplasty at proximal RCA ISR at another hospital. And then he visited at our hospital and has been following. His coronary risk factors were hypertension and hypertension. The echocardiography showed normal left ventricular function (EF=62%) with regional wall motion abnormality of RCA territory. The follow-up TMT was positive at stage 4 and thallium scan showed partially reversible large sized perfusion defect of inferior and mid to basal inferolateral wall.
Baseline coronary angiography
The right coronary angiogram showed in-stent total occlusion at pRCA with TIMI flow grade 1 ( Movie 1, Movie 2). The left coronary angiogram showed tubular 30% stenosis at pLAD and collateral flow from LAD and LCX to PDA and PL branches ( Movie 3).
Procedure
A 7 Fr sheath was inserted through right femoral artery, and the right coronary ostium was engaged with a 7Fr AL 1 catheter with side hole. Initially, we tried to insert Fielder FC 0.014 inch 190cm guidewire and BMW 0.014 inch guidewire via Finecross® 0.014 inch 130cm microcatheter into RCA. We failed several times for guidewire to pass into the RCA. Finally, 0.014 inch Ultimate 3 guidewire was inserted into RCA and exchanged to BMW 0.014 inch 300cm guidewire (Figure 1). Proximal RCA was predilated with 1.5 x 15mm IKAZUCHI balloon, 2.5 x 15mm SeQuent balloon, and 4.0 x 15mm Dura Star balloon sequentially (Figure 2, Figure 3, Figure 4). A 4.0 x 34mm RESOLUTE Integrity stent was deployed at pmRCA (Figure 5). Final angiogram showed successful stent expansion without periprocedural complications ( Movie 4, Movie 5).

Comments

  • Harris Ngow Ngow 2012-03-30 Thank you for this interesting case. I wonder how do you sizing the stent to vessel size as the initial angiogram did not show such a large vessel? Do you size by eyeballing, IVUS or OCT in this case? Thank you.
  • ANAZI 2012-04-04 most likely the sizing was decided on previous stent size

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