Case 99: PCI Manual - Balloon uncrossable and undilatable lesion

A young patient with diabetes presented with progressive angina. Diagnostic angiography showed 2-vessel cad with severe lesions in the proximal and mid right coronary artery and the second obtuse marginal branch. After discussion with the patient and the referring physician a decision was made to proceed with PCI, starting with the 2nd OM lesion. The lesion was balloon uncrossable despite using a 1.0 mm Sapphire Pro balloon. Using a Telescope guide catheter extension the lesion was crossed with a 2.0 mm balloon that had a waist and subsequently ruptured, causing a dissection. Additional balloons could not be delivered after the rupture and attempts to wire with a Viperwire Flex tip failed. A Turnpike LP was advanced distally but became “frozen” and had to be removed together with the guidewire. The lesion was rewired using a Viperwire Flex tip followed by several rounds of orbital atherectomy. Unfortunately, the lesion remained undilatable despite multiple additional balloons inflations. A decision was made to stop the procedure given radiation dose and re-examine treatment options (PCI of RCA only, re-attempt of OM2 PCI with laser/rotational atherectomy, or CABG).

[@matheuscsmed]

Thank you, Matheus Silva

[@rao00010]

Excellent case Manos. Kudos for showing a challenging case where you considered the risks/benefits of deferring further intervention.

[@amrhanafymahmoud9829]

Many thanks. Very useful. We want each hour useful knowledge

[@tom11298]

Thank you for the great case, one can never stop learning from your cases,
For me, I would not give it more than 1 attempt, given the diameter of 2mm of the 2nd OM, and the patent LAD, I would treat this vessel medically only..
and focus on the RCA PCI..

[@manosbrilakis]

Great point!

[@dr.med.s.almaghrabi3148]

Thank you very much.......best regards from Germany

[@mohammadjaber6387]

Many thanks great doctor

[@drgaganvelayudhan1733]

What could have been the reason the lesion still not yielding despite atherectomy? Would a tornus have helped?

[@manosbrilakis]

Likely heavy calcification. Tornus might have helped.

[@kalyanmuvvavenkateswarlu5482]

Excellent learning case sir

[@guozhuchen5511]

Thanks a lot! A good case for uncrossable and undilatable lesion. I have no experience with orbital athorectomy. In this case, how about use a rotawire to cross the lesion with the support of the microcatheter and then use 1.25mm burr, and followed by 1.5mm burr? Thank you again!

[@mohammadzaidan6186]

Great case Manos, thank you for sharing , do you think RA have a better/more predictable profile to be used after dissection in a vessel than OA? and in a long very tight lesion like this RA may have a better profile with frontal cutting compared to CSI where the ablating surface is 6 mm behind the tip .

[@manosbrilakis]

Agree - although in general would avoid atherectomy especially when a large dissection has occurred.

[@saeedalam4608]

I have Sapphire Pro 0.85×6 balloon with me which I got it when I was doing training in Japan

[@salahuddinsalahuddin3210]

The OM lesion didn't look very complex. Interesting and somehow scary how one could underestimate a stenosis' complexity..

[@kattadura007]

Would IVL with the help of guideliner (telescope catheter)be safer ?

[@manosbrilakis]

IVL could be quite useful but doubt that it could be delivered since even a microcatheter could not cross the lesion.