Case 131: PCI Manual - A great start!

A patient with 2-vessel coronary artery disease was referred for PCI of the right coronary artery and the LAD. The RCA had a significant ostial stenosis along with a 90% heavily calcified mid lesion with the PDA filling via collaterals from the LAD. During attempts for RCA PCI inadvertent contrast injection while the pressure was dampened resulted in extensive RCA dissection. The patient remained chest pain free without hemodynamic changes likely because of well-developed left to right collateral circulation. Attempts for reentry into the distal true lumen using a ReCross dual lumen microcatheter failed due to extensive subintimal hematoma. Retrograde crossing was successful but after wire externalization predilation and stenting there was no antegrade flow into the PDA and right posterolateral. Using a Mongo guidewire several passes were made into the PDA and right posterolateral restoring TIMI 3 antegrade flow without additional stent placement (STAR procedure).

[@fatherabdul]

Excellent Job Manos as always. ☕️☕️

[@user-pn3bh9sw1b]

Amazing and great case !! We should always pay attention to pressure before injecting contrast.

[@shangz0216]

Thanks for the educative case sharing.

[@ramidudin1]

Thank you for share this case, I think conclusion to secure distal wire before any inflation balloon or sent. Another point I will stop and avoid further contrast injection to avoid dissection expanding to right coronary sinus and ascending aorta because patient stable and she has good collateral from left.

[@arminmarashizadeh5540]

Thank professor for your educative case as usual, can you explain more about debranching ? How did you reentered?

[@jktg3049]

Can you explain what is and how to do "debranching"

[@farukakturk5388]

Thank you very much for shareing this case. I would like to ask what if you had another complication at septal artery that was keeping the patient stable?

[@manosbrilakis]

A problem with a septal branch would likely not be a big problem, but compromising LAD flow could be fatal. Using a safety wire and meticulous attention to ACT and pressure waveform are important to prevent donor vessel injury/thrombosis.

[@farukakturk5388]

@@manosbrilakis Thank you for your kind response. It is a great honor for me.

[@praveenalane4331]

Thanx for the case professor..what alternative wires do you suggest other than gladius for debranchibg in star approach ?

[@manosbrilakis]

Polymer jacketed guidewires, such as Fielder XT or Pilot 200.