Case 70: PCI Manual - Ostial and distal RCA lesion

[@basharmuhamad6679]

I would like to express my deepest gratitude and sincere thanks for limitless support and informative lecture.

[@AhmedElborae]

Thanks Dr Manos for the amazing demonstration, We have a similar case yesterday, and we had intentionaly jailed a wire in the conal branch by stenting the ostial RCA 1st (The reverse of classic teaching) and it worked well as an anchor for equipment delivery to the distal lesion. I want also to add a comment about using a distal stent as a platform for anchoring, this is not always free of complication (Expected to be safer than native vessel anchoring), i have a case of distal stent fracture following anchoring inside it. Thanks alot again for your amazing fruitful video series

[@manosbrilakis]

Excellent points, thank you. The first technique you describe (jailing a wire with a stent) is called "buddy wire stent anchor technique" and can provide strong support. Regarding distal anchoring by balloon inflation within a stent I personally have not had issues with it, but complications could still occur as you suggested.

[@bassemjerbi9039]

Hi Dr Brikalis, CAn we do distal anchoring with 6 Fr Guide wire? Is there a reference size for ballons?

[@osamakamal8296]

amazing demonstration as usual thank you prof

[@pinakinvparekh]

Hi Prof. Regarding distal anchoring with buddy wire (unstented area) --> I think we only can do it if the anchoring is done in a vessel which is intended to be stented anyway. I dont feel comfortable " POBAing" in normal vessels. Also kit has to be 7 french guide? 2 balloons for kissing inflations in a 6F is a tight squeeze. Let alone a stent and a balloon. Your wisdom is much appreciated Sir

[@manosbrilakis]

Great points! Agree that it is best to not balloon coronary segments that you do not plan to stent. Distal anchoring is done with 7 or 8 French guides.

[@farukakturk5388]

Sir, A couple of months ago ı had to stent left main ostium. We had excessive overhanging (procedure was döne under CPR). After the patient recovered on the table as a solution for overhanging i bend the overhanged part toward to aortic valve snd crossed the stent from bended part and made high atmosphere balloon inflation. Have you ever had a case like that ör what would you reccomend?

[@manosbrilakis]

I have not done this, but seems like a good solution. Would give prolonged DAPT in such cases.

[@farukakturk5388]

@@manosbrilakis Your video presentations are much more usefull than many of cardiology congresses.

[@RicardoGarcia-ym8tl]

Hi Dr Brilakis. At what atmospheres do you recomend inflate balloons for distal anchoring? 4 atm?

[@rajmaster0]

Yes, I had the same question. Do you just go up to nominal pressure? Thank you,

[@manosbrilakis]

It is usually high pressures - 12-20 atm. - Being inside the stent makes it usually safe.

[@tuanhoanh1198]

what is the size of the balloon and to which pressure do you use when we apply side branch anchoring and distal anchoring technique? Thank you

[@manosbrilakis]

Balloon is sized 1:1 to the side branch (usually they are small, 1.5-2.0 mm). Inflation pressure: 6-8 atm.

[@tuanhoanh1198]

@@manosbrilakis I really appreciate your answer

[@ruotianli8785]

Was there loss of side branches like conus in prox. RCA in this case?

[@manosbrilakis]

There were no major branches in this case, as far as I can tell. In general, occluing an acute marginal is unlikely to cause adverse consequences, but there have been cases of arrhythmias and/or ischemia when losing large acute marginal branches.