Case 171: Manual of PCI - The uncrossable lesion

A patient with exertional angina was found to have a severely calcified distal RCA lesion that could not be crossed by any balloons and was referred for repeat PCI attempt. The RCA was engaged with an AL1 8 French guide catheter. We were unable to cross the lesion with a guidewire, despite using a microcatheter and multiple wires with different bends at the tip. Eventually we used a Sasuke dual lumen microcatheter and were able to cross with a Gladius Mongo wire. However, the lesion was also “balloon uncrossable”. A Sapphire could not cross, despite using a deep seated guide extension. After grenadoplasty a Mamba Flex was delivered through the distal RCA lesion, allowing insertion of a Viper Flex Tip wire. After several rounds of orbital atherectomy the lesion was successfully crossed by balloons and expanded well. After DES implantation an excellent final result was achieved as confirmed by IVUS.

[@shangz0216]

Thanks for sharing.

[@usetherightbrain.]

" You shall not Cross"--- Mano- "Oh, yes I will!"

[@deguzmanaaron]

What is grenadoplasty?

[@manosbrilakis]

Inflation of a small balloon (usually 1.5 - 2.0 mm) at high pressure until it ruptures. The rupture may modify the plaque and facilitate subsequent equipment advancement.

[@farukakturk5388]

What if atherectomy also failed?

[@manosbrilakis]

Options include laser, various plaque modification balloons, extraplaque wire crossing.

[@farukakturk5388]

@@manosbrilakis
Sir if we went from around the lumen and after ballooning and we faced a rupture? What will be our options. Graft stents would be hard to deliver.

[@manosbrilakis]

@@farukakturk5388 Good question: equipment delivery is much easier in the extraplaque (subintimal space). Balloon and stent sizing should be more conservative in the extraplaque space and high-pressure balloon inflations avoided.

[@farukakturk5388]

@@manosbrilakis Thank you very much. I appreciate for your kind response