Tortuosity troubleshooting
Presenter
Evangelia Vemmou, MD, Minneapolis Heart Institute® - Abbott Northwestern Hospital, Minneapolis, MN
Evangelia Vemmou, MD1, Ilias Nikolakopoulos, M.D.1, Judit Karacsonyi, MD, PhD2 and Emmanouil S. Brilakis, MD, PhD, FSCAI1, (1)Minneapolis Heart Institute® - Abbott Northwestern Hospital, Minneapolis, MN, (2)Minneapolis Heart Institute Foundation, Minneapolis, MN
Title
Tortuosity troubleshooting
Introduction
An 82-year-old man, with a history of prior coronary artery bypass graft surgery (LIMA to LAD and SVG to first diagonal), atrial fibrillation, and chronic kidney disease presented with unstable angina. He had a recent non-ST segment elevation myocardial infarction that was medically treated.
Clinical Case
Diagnostic coronary angiography demonstrated severe disease in the left main with occlusion of the proximal circumflex and of the mid LAD, a 90% lesion the mid RCA (old lesions). The SVG to diagonal was patent but there was a 99% lesion at a highly tortuous segment of the diagonal branch distal to SVG anastomosis (culprit lesion). The SVG was engaged with a 6-French hockey stick guide catheter that fit moderately well and provided poor support. Wiring was challenging due to tortuosity but succeeded l using a Sion black wire. No balloon could be delivered due to tortuosity. A 6-French telescope was inserted but no balloons could be delivered including a 1.00 mm Sapphire Pro, as well as a Threader balloon. The Sion black was exchanged for a 300 cm Wiggle wire, but the Sapphire Pro balloon still could not be delivered. A buddy wire was inserted (another Sion black) and eventually a 1.0 mm Sapphire could be delivered, followed by 1.5 and 2.0 mm balloons. Attempts to deliver a 2.5 x22 mm Orsiro stent failed. The6-French hockey stick guide catheter was exchanged over the Wiggle wire for a 7-French AL1 guide catheter, but. the stent could still not be delivered despite multiple balloon inflations. Stent delivery still failed despite using a 7-French and the distal anchoring technique After additional lesion predilation, a 2.25x 30 mm Orsiro stent was delivered and deployed, partially covering the lesion. We encountered severe difficulty delivering a second stent. Eventually, after inserting a Grand Slam wire as a buddy wire, another 2.25 mm Orsiro stent was delivered, overlapping the previous stent. The vessel was postdilated with a 2.5 mm balloon with a nice final result and TIMI 3 flow into the diagonal branch.
Discussion
In case of tortuosity, polymer-jacketed guidewires can facilitate wiring. Techniques to improve support and modify the lesion can facilitate stent delivery.