Case 137: PCI Manual - Balloon uncrossable and balloon undilatable lesions

[@matheuscsmed]

Thank you, Matheus Silva

[@shangz0216]

Thanks for the educative case presentation.

[@hifa63]

Merci beaucoup, très intéressant

[@grjvlk]

Would vessel dissection with a heavily calcified intima flap offer an alternative explanation to as why the lesion became uncrossable? I had a similar experience after using a cutting balloon with high pressure (14-16) where I had to start almost from the beginning with low profile balloons ( did not escalate to rota bc patient had pain and ST elevations, I deemed there was not enough time for this). This case illustrates the degree of respect, skills and readiness to adapt to a changing situation when intervening in elderly patients with diffuse disease, an ever growing population the latest decade.

[@manosbrilakis]

Excellent point, this is certainly possible.

[@tofysoliman7494]

what about using IVL from the start it is a safer option than balloon rupture and microdissection after IVL ROTA WILL BE USED

[@manosbrilakis]

Good point - I would not use IVL here because it is such a long lesion and multiple IVL catheters would likely be required.

[@girishdeepak7708]

Did post stenting IVUS run demonstrate adequate stent expansion in the aneurysm areas?

[@manosbrilakis]

Good point, yes it did.

[@Saioffa]

Great case, it requires some nerves to do CSI in a dissected vessel. Also why CSI, is it because of the wire (viper file ) so had to use CSI or slow controllable Atherectomy? Final images showed some large septal got occluded so there was a dissection most likely. I did the patient become unstable with no flow in LAD and CTO of RCA? Would you use an Impella in such cases? Great 👍🏻 case

[@manosbrilakis]

Thanks for the excellent c omments. We used CSI because we could advance the Viper flex tip wire in the LAD. Patient remained hemodynamically stable - Impella could definitely help in case of hemodynamic instability.

[@llacielona]

imressive case!

[@Docsammy]

In retrospect a wiggle wire would have been a better parallel wire option.

[@manosbrilakis]

Excellent point!