A Case with Difficult Channel for Wiring
Dr. Raymond Chi-Yan FUNG, Dr. Simon Sai-Man WONG
Princess Margaret Hospital, Hong Kong
A 50-year-old male presented with exertional chest pain. Coronary angiogram showed normal left coronary artery, proximal right coronary artery (RCA) 70% stenosis, mid RCA 70% stenosis with a retroflex take-off adjacent to a short ectatic segment, distal RCA diffuse disease (Movie 1, Movie 2). All attempts to negotiate the true channel with single guidewire supported by microcatheter were exceedingly difficult. Guidewires (Sion blue, Fielder XT, Miracle 3) would end up prolapsing and falling into the ectatic segment (Figure 1). The straight microcatheter was exchanged to an angulated microcatheter but result remain unchanged (Figure 2). A dual lumen catheter was then used. Guidewires still failed to negotiate the channel. The ectatic segment was too short for reverse wiring. In the end only Fielder XT wire able to pass the difficult turn and went into mid RCA through the subintima.
At this time antegrade flow became sluggish after multiple wire attempts at the subintimal space. The dual lumen catheter was exchanged to a crossboss microcatheter which was used for blunt dissection at the subintimal space (Figure 3). It facilitated the subsequent positioning of stingray LP balloon. Antegrade dissection reentry (ADR) was performed with stingray guidewire (Movie 3). It was then exchanged to Fielder XT to advance into distal RCA (Figure 4). Guidewire position was confirmed by tip injection through microcatheter (Movie 4). IVUS assessment only showed a short segment of subintimal wiring. Distal to proximal RCA lesions were then treated with standard PCI procedure. Final angiogram showed good coronary blood flow with major side branches preserved (Movie 5).
The case illustrated that the use of ADR device is not limited to chronic total occlusion, it can also be used in other challenging situations.