Case 137: PCI Manual - Balloon uncrossable and balloon undilatable lesions

An octogenarian presented with unstable angina and was found to have 3-vessel disease with multiple, severe heavily calcified LAD lesions along with aneurysmal dilations between lesions, ostial disease in a small circumflex and CTO of the mid RCA. He was turned down for CABG and was referred for PCI of the LAD. Wiring was very challenging due to lesion eccentricity, but was eventually successful using a Caravel microcatheter and a Suoh 03 guidewire. A 300 cm long Grand Slam wire was inserted to the distal LAD. We had difficulty advancing balloons to the mid LAD and also had multiple balloon ruptures. The proximal LAD lesion was balloon undilatable. We tried to re-insert the Caravel microcatheter and exchange for an atherectomy guidewire but it could not be advanced. We also failed to advance a Turnpike LP and a Telemark microcatheter. We eventually parallel wired to the distal LAD with Viper Flex Tip guidewire, removed the wire from the ramus and did multiple orbital atherectomy runs in the proximal and mid LAD. There was transient slow flow that improved with balloon angioplasty. Stents were implanted from the ostium to the mid LAD with an excellent result as confirmed by IVUS.

[@matheuscsmed]

Thank you, Matheus Silva

[@shangz0216]

Thanks for the educative case presentation.

[@hifa63]

Merci beaucoup, très intéressant

[@llacielona]

imressive case!

[@grjvlk]

Would vessel dissection with a heavily calcified intima flap offer an alternative explanation to as why the lesion became uncrossable? I had a similar experience after using a cutting balloon with high pressure (14-16) where I had to start almost from the beginning with low profile balloons ( did not escalate to rota bc patient had pain and ST elevations, I deemed there was not enough time for this). This case illustrates the degree of respect, skills and readiness to adapt to a changing situation when intervening in elderly patients with diffuse disease, an ever growing population the latest decade.

[@manosbrilakis]

Excellent point, this is certainly possible.

[@Saioffa]

Great case, it requires some nerves to do CSI in a dissected vessel. Also why CSI, is it because of the wire (viper file ) so had to use CSI or slow controllable Atherectomy? Final images showed some large septal got occluded so there was a dissection most likely. I did the patient become unstable with no flow in LAD and CTO of RCA? Would you use an Impella in such cases? Great 👍🏻 case

[@manosbrilakis]

Thanks for the excellent c omments. We used CSI because we could advance the Viper flex tip wire in the LAD. Patient remained hemodynamically stable - Impella could definitely help in case of hemodynamic instability.

[@girishdeepak7708]

Did post stenting IVUS run demonstrate adequate stent expansion in the aneurysm areas?

[@manosbrilakis]

Good point, yes it did.

[@Docsammy]

In retrospect a wiggle wire would have been a better parallel wire option.

[@manosbrilakis]

Excellent point!

[@tofysoliman7494]

what about using IVL from the start it is a safer option than balloon rupture and microdissection after IVL ROTA WILL BE USED

[@manosbrilakis]

Good point - I would not use IVL here because it is such a long lesion and multiple IVL catheters would likely be required.