Case 80: PCI Manual - Failing all the way to success 2

A patient with prior coronary artery bypass graft surgery presented with NSTEMI due to a severe proximal right coronary artery lesion with an adjacent large coronary aneurysm. A decision was made to treat the lesion and the aneurysm. Using an 8 French guide via femoral access the lesion and the aneurysm were wired using a Caravel microcatheter and a Fielder FC guidewire. Despite predilation and use of a Grand Slam wire delivery of a 5.0x26 mm Papyrus covered stent failed. The RCA was re-engaged with an 8 French AL1 guide catheter but delivery failed again. An 8 French Guideliner was inserted to the mid RCA using the inch worming technique, through which a 4.0x26 mm Papyrus stent was successfully delivered and deployed treating the lesion and the aneurysm. After deploying a 4.0x18 DES all the way to the ostium a nice final result was achieved.

[@masahisayamane3847]

Another very much impressive case! Yes, key for success in this case is a choice of Fielder FC and persistence. Great case!

[@salahuddinsalahuddin3210]

I like your concept of failing all the way to success!! Thanks.

[@TheNEF11]

Brilliant managing! Amazing case. Thank you very much!

[@lahibimad]

Excellent educational case.

[@drroaaccu]

Good job, hard work

[@shermuhammadrozimatov5466]

Great case👍👍👍

[@user-qx5go6jw4d]

Very nice! Thanks!

[@dr.ahmedsaid]

Perfect

[@drahmedkamel]

Persistence

[@Kulseref]

If a major side branch emerged from the aneurysm site, what would your approach be like in this case

[@praveenalane4331]

Good case ... Do you perform any post dilatation for the covered stent ?? In any case if not this case .... 2.what would have been your option if there had been a thrombus in aneurysm ..would you plan pci or just thrombolyse and defer pci ?

[@manosbrilakis]

We did not perform postdilation of covered stent except for the overlap segment with the proximal DES, as IVUS showed good expansion; however postdilation in recommended, especially for the GraftMaster stent, which is hard to expand. If thrombus was present within the aneurysm, but antegrade flow was still present and wiring could be done without disrupting the thrombus and embolizing would probably treat with covered stent. Otherwise, can consider heparin or GP IIb/IIIa infusion with repeat angio and PCI after 48 hours.

[@tom11298]

great skills placing ostial stent with AL. when you place the ostial DES overlapping the papyrus, do you postdilate tbe overlapping zone of both stents separately?

[@manosbrilakis]

Excellent point - yes, by advancing the stent balloon in after stent deployment.

[@ahmadsamirmohamedabdelhami115]

Amazing case I know u did post stenting IVUS there is some shelfing at the distal stent edge (outlet of the aneurysm), what did the IVUS tell about it?

[@manosbrilakis]

Could not advance the IVUS all the way past the covered stent, so unfortunately do not know!

[@ahmadsamirmohamedabdelhami115]

@@manosbrilakis thanks.. But realy very educative case (as usual)