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Severe distal RCA lesion in a 53-year-old man
by Emmanouil S. Brilakis, MD, PhD, and Subhash Banerjee, MD
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A 53-year-old man presented with severe exertional angina and inferior ischemia on noninvasive testing. Coronary angiography revealed a severe distal right coronary artery lesion (Figure A) with mild disease in the left coronary artery.
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| Emmanouil S. Brilakis |
Percutaneous coronary intervention was attempted through a 6 French JR4 guide. Wiring the distal right coronary artery (RCA) was difficult due to preferential wire entry into a large acute marginal branch, but was eventually achieved using various bends on several polymer-jacketed wires. Similarly, balloon delivery to the distal RCA (arrow, Figure B) was difficult but was achieved by placing a coronary guidewire into a large acute marginal branch (arrowhead, Figure B). Delivering a 2.5 mm × 23 mm or a 2.5 mm × 12 mm stent (arrow, Figure C) failed, despite additional lesion predilation, using two buddy wires, exchanging the wire for an Ironman wire (Abbott Vascular) and using a Guideliner guide catheter extension (Vascular Solutions; arrowhead, Figure C). We attempted to use a side-branch anchor technique by inflating a 2.5-mm balloon in the acute marginal branch, but were unable to advance a stent through the 6 French guide.
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| Subhash Banerjee |
Because of the difficulty wiring the RCA, we elected to exchange the guide catheter for a larger and more supportive guide over the Ironman guidewire. The JR4 guide was removed from the RCA (arrow, Figure D), and after insertion of an 8 French sheath in the right femoral artery, the RCA was engaged with an 8 French AL1 guide without losing guidewire position (arrowheads, Figure D). Stent delivery continued to be challenging but was achieved after a 2.5-mm balloon was inflated within the acute marginal branch (arrow, Figure E; side-branch anchor balloon technique).
After implantation of proximal and distal RCA stents, significant disease remained in the midsegment (Figure F) requiring implantation of additional stents, which was achieved using an 8 French Guideliner catheter and a buddy wire, providing an excellent final angiographic result (Figure G). The patient had an uneventful recovery and was dismissed from the hospital the following day.
Discussion
Delivering equipment to a coronary lesion is at the core of PCI. Although advances in equipment design have significantly facilitated delivery, some lesions, especially in the calcified and tortuous vessels, may be challenging to reach, forcing us to go back to the basics and apply various techniques to succeed. These techniques can conceptually be grouped in three categories (Table, see page 10): increasing guide catheter support; preparing the lesion; and changing the equipment that is to be delivered.
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Images: Emmanouil S. Brilakis, MD, PhD |
Good guide catheter support is critical and can easily be achieved by using larger and more supportive guide catheters. Upsizing from a 6 French JR4 to an 8 French AL1 guide enabled stent delivery in our patient. When difficult equipment delivery is anticipated, it may be best to start the intervention using a large guide catheter. Yet, if the need for extra support becomes evident after a wire has been placed across a difficult-to-wire lesion, exchanging the guide catheter over a stiff coronary guidewire avoids uncrossing and recrossing the lesion (Figure D). Careful preparation of the subcutaneous tissue at the arterial access site can minimize the difficulty of inserting a new larger arterial sheath over a 0.014-inch guidewire. Certain techniques, such as the side-anchor technique, require at least a 7 French guide catheter. Ensuring coaxial guide alignment using orthogonal views and deep engagement, for example by clockwise rotation of a JR4 guide, can also help, but was not feasible in our case due to small vessel caliber. Using long femoral artery sheaths (such as 45-cm long sheaths) can also facilitate guide manipulations and improve guide catheter support.
Using one or more buddy wires or using a stiff guidewire are additional simple and low-cost solutions. More advanced but also higher yield techniques include the use of guide catheter extensions or anchor-balloon techniques. The Guideliner catheter is a simple-to-use, rapid exchange, guide catheter extension that was recently approved for use in the United States to deeply intubate a coronary artery. It is available in three sizes that fit within a 6, 7 and 8 French guide catheter.
When a Guideliner catheter is utilized, attention should be paid to minimize the risk of vessel injury and stent loss that can occur at the transition point from the guide catheter to the Guideliner lumen. Another option is to use the Proxis embolic protection catheter that requires a 7 French or larger guide and is an over-the-wire system. Anchor techniques can also improve guide catheter support by inflation of a balloon into a side branch of the target coronary artery (side-branch anchor) or at the target lesion (distal anchor).
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Adequately preparing a lesion is important both for facilitating equipment and for minimizing the risk for stent underexpansion. This can be accomplished by balloon predilation, often using high-pressure noncompliant balloons or using scoring balloons, such as the cutting balloon or the Angiosculpt (Angioscore). Rotational atherectomy can be beneficial in calcified vessels, but may carry increased risk for injury when used in tortuous vessels, as in our case. Specialized penetration catheters, such as the Tornus and the Corsair (Asahi Intecc), can create a channel through “balloon uncrossable” lesions to facilitate subsequent balloon delivery.
Finally, using shorter, lower-crossing profile, and more flexible stents can help. In our case, we could not deliver a 28-mm long stent but were able to deliver a 12-mm long stent. Although using multiple short stents instead of fewer long ones can increase the cost of the procedure, this may be the only way to successfully stent a lesion.
Conclusion
Frequently, no single technique may suffice; combinations of techniques (such as larger and more supportive guide and side-balloon anchors; Figure E, see page 9) may be needed. Rapid transition between various techniques may provide the best chance of success, rather than spending a prolonged period of time trying the same failing technique. As shown in the Table, 10 different techniques were used in the present case before it was successfully completed.
Currently, most PCIs proceed as planned without the need for specialized and complex strategies. However, when difficulties arise, going back to the drawing board and revisiting the basics of equipment delivery can make the difference between success and failure. And there is no interventionalist that likes failure.
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Subhash Banerjee, MD, is chief of the Division of Cardiology and co-director Cardiac Catheterization Laboratory, VA North Texas Health Care System, Dallas, and is associate professor of medicine at the University of Texas Southwestern Medical Center, Dallas; Emmanouil S. Brilakis, MD, PhD, is the director of the Cardiac Catheterization Laboratory at the VA North Texas Health Care System, and is associate professor of medicine at the University of Texas Southwestern Medical Center. Drs. Brilakis and Banerjee are also members of the Cardiology Today Intervention Editorial Board.
Disclosure: Dr. Banerjee has received speaker honoraria from St. Jude Medical, Medtronic and Johnson & Johnson, and research support from Boston Scientific and The Medicines Company; Dr. Brilakis has received speaker honoraria from St. Jude Medical and Terumo, research support from Abbott Vascular and InfraReDx, and his spouse receives salary from Medtronic.