Calcified and “Leaky” Vessel
Dr. Alan Ka-Chun CHAN
Mr. Cheung, a 70-years old gentleman, was referred for unstable angina. Computer tomographic coronary angiogram showed calcified triple vessel. Coronary angiogram showed ulcerated plaque in distal left main, calcified LAD and LCX critical stenosis (Movie 1, Movie 2) while RCA was totally occluded (Movie 3). PCI to LCX was uneventful. PCI to LAD was performed at the same session. After high pressure predilation to mid LAD with a NC 2.5 balloon, type III perforation was resulted and patient quickly developed pulseless electrical activity. Immediate balloon tamponade and pericardiocentesis were performed which resolved cardiac tamponade (Movie 4). There was persistent leakage despite prolong balloon tamponade and blood pressure dropped once the balloon deflated. Stent graft was decided to use and another femoral access was prepared for ping pong guide. A DES was first delivered down beyond the perforation site to treat distal LAD stenosis (Movie 5). A stent graft was deployed and treated the mid LAD while another DES was delivered and treated the LM to proximal LAD. Perforation sealed off with satisfactory angiographic result (Movie 6). The patient remained stable afterwards and was discharged few days later.
He was brought back to cath. lab 3 months later for stage procedure of mid RCA CTO. The occlusion is calcified with more than 20mm in length (J-CTO score 2) (Movie 7). Antegrade wire escalation was planned as first approach while antegrade dissection reentry followed by retrograde approach were planned if failed. XTR guidewire supported by microcatheter was first used (Figure 1) followed by Gaia 2nd guidewire (Figure 2). It went into subintimal plane. Parallel wire with a Gaia 3rd guidewire was attempted but again went into subintimal plane (Figure 3). A hyperdense collection was noticed around mid RCA while patient remain hemodynamic stable (Movie 8). Immediate echocardiogram did not show frank pericardial effusion. Slow oozing of blood from guidewire perforation was suspected. Immediate action to prevent further leakage was warranted as there may be risk of further expansion of the localized hematoma with possible “dry tamponade” in view of previous history of pericardial blood/drainage. The quickest method in this scenario would be antegrade dissection reentry so that the leakage would be stopped once dissection plane developed across the occlusion. It was easily accomplished by XT guidewire knuckling and Guidewire advanced beyond the CTO segment into distal RCA (Movie 9). Microcatheter was exchanged to Stingray balloon and reentry was completed with “stick and swap “technique (stingray needle followed by pilot guidewire) (Movie 10, Movie 11, Movie 12). Satisfactory angiographic result was achieved after 3 DES were implanted (Movie 13). Follow up echocardiogram showed no frank effusion and patient remained stable. He was discharged few days later and remain chest pain free in subsequent follow up.
