Case 128: PCI Manual - Acute vessel re-occlusion

A patient presented with NSTEMI and was found to have thrombotic occlusion of the distal RCA with an ulcerated lesion in the mid RCA. Wiring the RCA was challenging but was achieved using a Sion black guidewire and a Caravel microcatheter. Thrombectomy was performed using an Export catheter and the Penumbra system. A large amount of thrombus was retrieved restoring antegrade coronary flow. A stent was delivered to the distal RCA, but attempts to deliver a 3.5x38 mm DES led to guide and wire position loss. The RCA could not be rewired (the wire entered the subintimal space). Re-entry with a Stingray balloon failed. Retrograde crossing also failed. Repeat attempts for antegrade wiring were successful using the Stingray balloon and a Gladius Mongo guidewire, followed by stenting, repeat thrombectomy and an excellent final result.

[@tom11298]

Perfect case and great learning points.
Sometimes mild disease in the RCA would be enough to make deliverability of big stents using radial and judkins very challenging, hence AL or Ikari L plus GC extension from the beginning would be great…
Thanks again we keep learning from you 👍

[@shangz0216]

Thanks for the educative case sharing.

[@jwilson3985]

Man this Lesion needs an AL guide, no? But great case thanks for sharing.

[@tom11298]

AL or Ikari L 3.5 with GC extension, some mild disease in the RCA would be enough to make delivery of big stents very difficult using radial and Right judkins..

[@sebastianvasilescu]

AL + Guideliner ftw .. but very interesting case !

[@Stentordoc]

Exactly my thoughts. Better preparation with a supportive guide and adequate predilation will prevent a 10 minute case from turning in a 3 hour case

[@manosbrilakis]

Great point - in general JR4 should not be used for RCA PCI via radial access due to poor support.