An 85-year-old man with a history of coronary artery disease underwent a previous catheterization in 2009 with borderline significant angiographic disease of the left anterior descending coronary artery (LAD) and right coronary artery (RCA).
At that time, the patient underwent diagnostic angiography and was found to have high-degree stenoses of the LAD and RCA. However, because of contrast-induced nephropathy, his intervention had to be staged. The patient presented for revascularization of the RCA, felt to have most angiographic progression since 2009. He previously had been evaluated for coronary artery bypass graft surgery and was turned down in 2009.
- Rotational atherectomy.
- Intravascular ultrasound (IVUS) and stent of the RCA with a 3.0 x 15mm Integrity bare metal stent (BMS) (Medtronic) distally and a 3.0 x 15mm Integrity BMS proximally.
The right radial artery was prepped and drapped in a sterile fashion. The right radial artery was accessed with a 6 French Glidesheath (Terumo) and initially engaged with an Amplatz right (AR) modified guide catheter; however, there was poor guide support. Given the tortousity of the innominate artery, we upsized to a 6 French 65 Pinnacle Destination sheath (Terumo) and an Ikari right guide catheter (Terumo) of 1.0, which gave fairly good support. After bivalirudin (Angiomax, The Medicines Company) was administered, we advanced a Runthrough wire (Terumo) with an over-the-wire balloon. With the previous guide wire, we had done the same thing and had actually been able to advance the Rotawire (Boston Scientific), but everything backed out during an attempt to advance the Rotablator (Boston Scientific) with the AR modified guide catheter. We then exchanged distally for a Rotawire and advanced a 1.5mm burr.
A Runthrough wire was re-advanced. A second wire was advanced with an over-the-wire balloon and distally exchanged for a Wiggle wire (Abbott Vascular). IVUS of the proximal lesion was performed and the vessel was found to be 3.0 mm. IVUS could not be advanced in the distal vessel.
A 3.0 x 10 mm AngioSculpt scoring balloon catheter (AngioScore) was used to predilate the proximal lesion. We could not advance the AngioSculpt distally, given tortuosity and calcification of the mid RCA, although it was not angiographically significant. We dilated with a 3.0 x 12 Emerge balloon, with two wires in place, then attempted to advance a 3.0 x 15mm Integrity stent distally and were unable to do so. We took a 6 French GuideLiner catheter (Vascular Solutions) and were able to advance the stent through the GuideLiner distally and deploy it at 14 atm. The GuideLiner was removed and the proximal lesion was stented with a 3.0 x 15mm Integrity BMS.
Final angiography revealed TIMI-2 flow without dissection, perforation or embolization. Some calcification and intermediate angiographic disease of the RCA remained. The patient tolerated the procedure well. A TR Band (Terumo) was placed over the right radial artery.
Patient management plan
- Dual antiplatelet therapy.
- Risk-factor modification.
- Stage the patient for revascularization of the LAD, as long as renal function is stable.
Orlando Marrero can be contacted at email@example.com. Dr. Zaheed Tai can be contacted at firstname.lastname@example.org.