Case 185: Manual of PCI - Calcification + tortuosity

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A patient was referred for PCI of heavily calcified and tortuous right coronary artery. He also had prior CABG with LIMA to LAD and a lesion in the left subclavian proximal to the LIMA origin. A pressure wire was advanced across the lesion but did not show a significant gradient, hence subclavian intervention was not performed.
The RCA was engaged with an AL1 guide. Wiring was challenging but was achieved using a Corsair XS microcatheter along with multiple guidewires (Sion black and Suoh 03). The microcatheter could not be advanced distally until after dilatation with a 1.0 mm Sapphire and a 2.0 mm Takeru balloon. Several runs of orbital atherectomy were performed but were stopped after the patient developed significant ST segment depression. During attempts to deliver a stent distally through a guide extension the stent got stripped off the balloon and was deployed using sequentially larger balloons (1.5 to 3.0 mm). A short Orsiro stent was successfully delivered distally followed by several Onyx stents more proximally with an excellent final result.
Category
Cardiology
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