Case 132: Manual of PCI - PCI through 2 TAVRs

A patient with two prior TAVR procedures (31 mm CoreValve implanted 6 years prior and 29 mm Sapien 3 implanted 2 years prior) presented with chest pain and inferior ischemia. Coronary angiography was challenging: a JR4 diagnostic catheter failed to engage but engagement was achieved with a 6 French multipurpose diagnostic catheter. The culprit lesion was a 90% mid RCA lesion. Engagement with a JR4 and a multipurpose guide catheter failed. We engaged the right coronary artery with a multipurpose diagnostic catheter and inserted a workhorse wire and a 300 cm long Grand Slam guidewire. We removed the diagnostic catheter leaving the Grand Slam guidewire in place and inserted a JR4 guide catheter over the Grand Slam wire. We then inserted a 6 French guide catheter extension that improved engagement of the right coronary artery. OCT suggested that the lesion was a calcified nodule. We performed several runs of orbital atherectomy followed by successful balloon expansion and DES implantation.

[@shangz0216]

Thanks for the educative case sharing.

[@ramidudin1]

Excellent job. I think The Aorta was dilated which make engagement difficult .

[@micger]

Good case! What is the pouch seen at the ostium?

[@ronak456]

In final result, was there a dissection near RCA ostia???? There is some contrast hanging seen...

[@manosbrilakis]

I think this is the space between the coronary sinus and the TAVR valve.

[@ronak456]

@@manosbrilakis Yes sir... Agreed... Searched for this one on google scholar..

[@farukakturk5388]

If there is not a supportive wire in the lab would you stent this via the diagnostic catheter?

[@manosbrilakis]

Probably not - there is a significant risk of losing the stent

[@farukakturk5388]

@@manosbrilakis Thank you sir