Case 159: Manual of PCI - I closed the vessel
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- Опубликовано: 7 окт 2024
- A patient presented with NSTEMI and was found to have a severe lesion in the proximal RCA that had shepherd’s crook morphology. The RCA was engaged with an AL1 guide using radial access and the lesion was predilated but guide support was limited and guide and wire position was lost. The RCA was re-engaged with a Hockeystick guide but the RCA became occluded likely due to dissection. A workhorse guidewire could not be advanced to the true lumen. We attempted reentry in the mid and distal RCA using a Stingray balloon without success. IVUS showed a large extraplaque hematoma. We attempted subintimal hematoma aspiration through the Stingray balloon itself but also through a Corsair microcatheter but reentry still failed. Retrograde crossing attempts also failed. Using the STAR technique Gladius Mongo wires were advanced to the right posterolateral and the right PDA. IVUS showed decrease in the size of the hematoma and final reentry attempt with the Stingray was successful using the “stick and drive” technique, followed by stenting and restoration of flow in the RCA.
Thank You very much for case presentation, Professor Emmanouil Brilakis. I have used antegrade fenestration and reentry technique, after hematoma aspiration(with balloon blockage of antegrade flow), in case like this. It was on my night duty, but I had many time to enter in true lumen of RCA. Your words about knowledge of CTO techniques in acute situation on coronary vessels I have in my mind all of time.
Excellent point, thank you.
Very smart move to attach penumbra for continuous suction!
I would have inflated balloon at the proximal RCA (u did it at the beginning anyway) to completely block the blood flow,and then we may do suction. I think it will help a bit. Very educational case
Thank you very much for your comment!
Why not use a second wire at start to straighten the bend and predilate with smaller balloons? It looks like the 2,5 was inflated before the lesion. What came after was so complicated and requires so much equipment / cost…
Agree with you - we did not anticipate we were going to have so many difficulties with this case.
Thanks for the educative case presentation.
Excellent save sir.
But it can be prevented also, I think gradual predilatation with smaller balloon 1.5 then 2 and 2.5 mm would be helpful.
Good point - thank you.
Thank you sir for sharing this case with us. I am learning a lot from you. I have a question: Would you also consider using DCB instead of a stent where the dissection is at? So we don’t compromise the RPL. Considering it’s a dissection with a timi 3 flow. Then maybe the dissection will eventually heal.
Perfect
correct me if i'm not right... so basically the second stent in the middle RCA was depolyed at the subintimal area right?
Thank you for sharing the case sensei, I had learnt alot by following your channel and has help me alot to anticipate, prevent and overcome challenges and complication … For iatrogenic vessel closure due to haematoma compression, I had several luck securing true distal lumen by reducing the haematoma with manual aspiration, in your case mechanical aspiration was chosen. However, My question is regarding the decision to stent to the right PDA instead of to the PL branch,.I would have stent to the PL which subtended a larger area of myocardium. Was the imaging guided you to stent to the PDA instead of the PL ? If it were the imaging, can you give some a pointer ?
Excellent point - thank you - agree that the posterolateral could have been stented instead. The reason for stenting into the PDA was that the dissection extended there and had we stented the posterolateral we might have occluded the PDA.
Excuse me for my question, but i want to know. Where was the point of reentry in RCA, and if it was before the bifurcation of RCA, can we use double lumen microcatheter in this case, to wiring PLB on bifurcation level? The question is important for me, Professor Emmanouil Brilakis: many nights i 'm on duty, and many cases I have, when I can close the vessel. Thank You.
There seems to be dissection in proximal rca.
How about using al star wire to straighten the bend.
What about mother in child technique for better support?
Good points - the problem was that true lumen wiring failed after the RCA dissected, hence we could not use the techniques that you mentioneed.
Instead of changing catheter after predilating a tortous segment why not use a guideliner or buddy wire
Great suggestion - could have done what you described.
Bhai chaalam challaa kar diye
I have Q sir, would you consider CT surgery consult initially with this critical RCA stenosis and LAD lesion? also why you didn't try guide extension since you ballooned lesion and wire still in true lumen? Thanks
Excellent point - the reason for PCI is low Syntax score in a non-diabetic patient. Guide extension would have helped, but wire position was lost prior to using it.
Great, Any advice to tame the dangerous AL1? May I assume that the dissection was caused by the AL1 from the very beginning just digging into a tight area? and thats why no instruments went through from the start?
We think that the dissection occured after ballooning - when wire position was lost rewiring went through the dissection plane. AL1 can definitely cause dissections though.
Seems like you’re using Suoh 3 more now antegrade instead of it’s traditional surfing role. Can you elaborate a bit on why?
The reason for Suoh 03 in this case is to minimize the risk of extending the dissection (since Suoh 03 is such a soft wire).
WHAT THE TOTAL COSTS OF THIS PROCEDURE?? CAN YOU REPORT?
Do not have a number but the cost was certainly high.
TKS. YOUR JOB IS REALLY FANTASTIC. CONGRATULATIONS FROM BRAZIL - RIO DE JANEIRO.