Case 76: PCI Manual - Wiring challenges

A patient was referred for PCI of a highly tortuous right coronary artery after turning down CABG. He also had a CTO of the mid LAD. Engagement of the RCA was challenging. Using a short femoral sheath and an AL1 guide failed. A JR4 guide successfully engaged the right coronary artery but provided poor support and guide position was lost during attempts to advance a 6 French Trapliner.
The femoral sheath was changed to a 45 cm long sheath that improved handling of the guide catheter. Delivery of the Trapliner was initially successful using the inch-worming technique, but its position was subsequently lost. Using the side branch anchor technique with a 2.0 mm balloon in a large acute marginal branch allowed delivery of a Caravel microcatheter to the mid RCA proximal to the target lesion. Despite using multiple guidewires (Sion, Fielder FC, Sion black, Suoh 03, Pilot 200, Gladius Mongo) the target lesion could not be crossed. Because of concerns for hemodynamic compromise if the RCA flow was disrupted (due to the LAD CTO) the procedure was stopped and the patient was encouraged to reconsider CABG.

[@dobryi_chel]

"Know when to stop" - it is main rule. Thank You so much professor, for interesting case.

[@TheNEF11]

Excellent educating case! With a very important message for (imo) all of us.

[@tom11298]

sometimes less is more! great decision stopping at that point.
without the CTO of the LAD and the collaterals from right to left more attempts would have been possible..
Thank you for sharing this case sir

[@manosbrilakis]

If the patient did not have LAD CTO another option would be to dissect proximally and re-enter distally, but this strategy also has inherent risk of ischemia and failure to re-enter.

[@mohammedelbarbary8708]

Nice case

[@abdulazeezissa7964]

Thank you very much

[@shamsrehan8942]

Very challenging sir

[@farukakturk5388]

Sometimes less is more as you said before. And still waiting for reversed guidewire tecq demo :)

[@mohamedkishkt3667]

a wisdom say ... thanks

[@harsh4082000]

why did AL not work..I think the fundamental issue in the case was guide support. I guess AL 0.75 or AR 1/2 did not work.

[@jwilson3985]

Great case. Learn a lot watching expert operators abort cases. Any thought to trying a grandmother-mother-daughter technique with a 6F GL in the pRCA and then adv a 5.5F GL to see if that could advance into the mRCA? 🙏🏻

[@manosbrilakis]

This could be tried, however the issue was not support (side branch anchor and Caravel provided strong support). The issue was pushing too hard and possibly dissecting the lesion with acute vessel closure.

[@MuhammadSulemankmc]

Leave when you are winning

[@rengagovind727]

Challenging case sir

[@Strongcardiology]

Hi sir .. is there a PDF version of MANUAL of percutaneous coronary intervention?

[@TheNEF11]

according to Mr. Brilakis the book will be available May 2020 at the time of the SCAI meeting. I'm not sure if there will be any PDF-version. But I also can highly recommend the "manual of chronic total occlusion Intervention" by Mr. Brilakis