Case 79: PCI Manual - Failing all the way to success 1
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- čas přidán 24. 03. 2020
- A patient with chronic kidney disease was referred for PCI of the RCA and the proximal LAD. The procedure was performed via radial access. Coronary engagement was challenging. The RCA was engaged using an AL1 guide catheter and stented. Attempts to advance an IVUS after stenting failed, the AL1 guide kinked and wire position was lost. The RCA was re-engaged but rewiring was challenging in part due to difficulty achieving co-axial engagement. This caused an aortocoronary dissection and wire position was again lost. The RCA was engaged with a 6 French JR4 guide catheter and rewired with a workhorse wire, followed by ostial stenting and confirmation of ostial coverage with IVUS imaging.
Engaging the left main was also challenging, but was eventually achieved with an EBU 3.75 guide catheter. The LAD was wire with difficulty but the target lesion was balloon undilatable and the balloon ruptured. A Chocolate balloon failed to expand the lesion. Orbital atherectomy was attempted but during attempts to deliver the crown guide position was lost and re-engagement was challenging. We obtained femoral access and were able to easily engage the left main with a 7 French EBU 3.75 guide catheter. Several passes of orbital atherectomy were performed, however the lesion still failed to dilate and a distal dissection was seen. A 3.0x40 mm peripheral intravascular lithotripsy balloon was used to deliver 100 pulses, following which the lesion expanded. The proximal LAD was stented, but subintimal hematoma was seen in the mid LAD that was treated with implantation of one additional stent with a nice final result.
This cases illustrates how overcoming several failures and obstacles one by one can eventually lead to success. - Auta a dopravní prostředky
Thank you, Matheus Silva
Very informative case! Very small contrast volume for such a demanding case..
Ikrari Right 2 usually gives great support from radial for usual RCA cases..and ofcourse AL1 for more complex ones
Great point!
👍
Thanks Manos, when we have a dissection or in this case intramural hematoma, I always prefer to cover the distal part first with the stent and if needed deploy another stent in proximal but you did the opposite, I just want to know your expert opinion?
Wow. Great case. IVL worked like a charm! Did you have it in the lab or did you have to send someone to the peripheral lab to get it? We don’t have any IVL yet :(. Playing Monday Morning QB, do you think it would have been better to either 1) go femoral earlier or 2) stage the LAD in 1-2 weeks? Thanks much for posting Dr Brilakis.
We do have peripheral IVL in the lab. In retrospect staging the LAD would have been the way to go!
Great case! Thank you for sharing...our lab has Intravascular Lithotripsy (Shockwave) but only for peripheral. We are also not able to use it ad hoc. What stages did your lab go through to be able to use it for coronary interventions?
We also only have peripheral intravascular lithotripsy which we use off label in the coronaries. We were able to use it after several cases in which all other approached failed, similar to this one.
it was a great case with the awesome end result but I was wondering why staged PCI was not an option in this case with CKD and calcified vessels?
Staged PCI is definitely an option and would have been the preferred option had we known how challenging LAD PCI was going to be.
Femoral would have been better sir?
The strange thing is CSI didn't work but IVL did. Do you think this will be the future?
Prediction are hard, especially about the future! Nevertheless, IVL seems very promising.
Flaring the ostium - Ostial Flash ?
Great point, Ostial Flash could facilitate re-engagement if future caths are needed.
What are the IVL balloon sizes???
Must have new/trial IVL balloons because 3.0 x 40mm doesn’t exist for standard Shockwave. Maybe it’s a trial patient for Disrupt CAD III 🤷🏻♂️
We used the S4 catheter which is 135 cm long with 4 emitters and is designed for BTK. Sizers are 2.5x40, 3.0x40, 3.5x40, and 4.0x40 mm.
Tq sir