Case 159: Manual of PCI - I closed the vessel

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.

[@user-su4he3ju7t]

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.

[@kathorhanes]

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…

[@aq4019]

Very smart move to attach penumbra for continuous suction!

[@shangz0216]

Thanks for the educative case presentation.

[@SoonKyu515]

correct me if i'm not right... so basically the second stent in the middle RCA was depolyed at the subintimal area right?

[@roerebs4261]

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.

[@yasseralmayali7680]

Perfect

[@kadad5220]

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

[@drmz2007]

Excellent save sir.

[@djuzar]

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 ?

[@ahmedzahran7016]

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?

[@abhimanyusa]

Bhai chaalam challaa kar diye

[@NikhilJha89]

There seems to be dissection in proximal rca.

[@jwilson3985]

Seems like you’re using Suoh 3 more now antegrade instead of it’s traditional surfing role. Can you elaborate a bit on why?

[@fh677]

Instead of changing catheter after predilating a tortous segment why not use a guideliner or buddy wire

[@rogeriomoura6557]

WHAT THE TOTAL COSTS OF THIS PROCEDURE?? CAN YOU REPORT?