Case 188: Manual of PCI - Externalization for non-CTO PCI

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A patient with prior CABG presented with NSTEMI due to a severe lesion of the right PDA at the site of a SVG anastomosis. The lesion was highly angulated due to tenting of the native coronary artery by the SVG which was occluded. A prior attempt to treat that PDA had failed.
We were unable to wire through the lesion but were able to advance a guidewire into the occluded SVG. We tried several guidewires, including Sion black through a Turnpike LP and a Sasuke microcatheter but were unable to wire the PDA. The reversed wire technique also failed. After multiple attempts we retrogradely crossed the occluded SVG and externalized a R350 guidewire. We advanced a Sasuke over the externalized guidewire and were able to wire distally into the PDA. We did kissing balloon inflation (one balloon from the native RCA into the SVG and one balloon from the SVG into the distal PDA). We used the reversed guidewire technique again with a Sasuke and Sion black. The knuckled Sion black advanced through the native RCA into the SVG and then entered the distal PDA upon withdrawal. The Sion black was exchanged for a Wiggle wire, followed by balloon angioplasty and stenting of the PDA.
Category
Cardiology
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