Title
Challenging lesion in a STEMI: difficulty in crossing culprit lesion
Introduction:
In STEMI, failure or delay in crossing culprit lesion leads to a poor outcome including decreased myocardial salvage.
Clinical Case:
68 yo female presented to satellite hospital with chest pain and EKG showing inferior STEMI. There she underwent diagnostic angiogram through R radial access that showed 99% severely calcified distal RCA lesion with TIMI flow 2.Using JR4 guide and PILOT 50 wire the lesion was crossed but was uncrossable to the balloon. She was transferred for ROTA PCI to our hospital. Femoral artery access was obtained using a 6 French sheath. A 6 French AL-1 guide provided marginal support, assisted by a 6 French guide extension. Over Turnpike LP, advanced to the lesion, which appeared to have been dissected during the prior intervention attempt, with a Runthrough wire that was unable to cross. Wire escalation was performed with Sion Black, Choice PT XS, PT graphix intermediate, Pilot 200, and Gaia 2, but none would cross. With engagement of the lesion with the Turnpike the guide and extension would progressively disengage, and ultimately equipment was lost. We then exchanged for a 6 French AL-2 guide catheter (after 6 French MP unable to engage) for improved support, and reattempted wire crossing unsuccessfully. Interim angiography showed worsened dissection with distal vessel occlusion. We then attempted to STAR into the distal vessel with the Pilot 200 unsuccessfully due to the heavily calcified plaque. Reattempt to cross with the Pilot 200 and entered the true lumen in the distal RCA before the crux and was able to wire both the RPL and RPDA. At this point the patient developed VF with ROSC after brief CPR and 1 shock, regaining stable hemodynamics and metal status. We then attempted to cross the stenosis with Turnpike LP and then Turnpike spiral microcatheters, but these would not pass. The guide extension was then advanced to the distal vessel using balloon anchor, but again microcatheters nor a 1.5mm Takeru balloon would cross. Next we parallel wired into the RPDA successfully with a Rotawire Drive, removed the Pilot 200 and guide extension, and proceeded with rotational atherectomy using a 1.5mm burr at 155k rpm. After the first pass, the patient developed bradycardia and hypotension that responded to IV atropine, but she continued to clinically deteriorate, required intubation to complete the procedure. Venous access was obtained and a TVP was placed into the RV apex, then performed 2 additional passes with the 1.5mm rota burr. The Rotawire was then exchanged for a Wiggle wire, the lesion predilated with 3.0mm NC and 3.5mm NC balloons with good expansion. A 3.5x18mm DES was deployed and post-dilated with a 3.5mm NC balloon to high pressure. Post IVUS revealed no dissection or thrombus, good apposition and expansion. Final angiography revealed normal flow, no dissection and 0% residual stenosis.
Discussion:
Severely calcified lesion in STEMI may require good guide support, guide extension, microcatheter and wire escalation with preparedness to use anterograde CTO crossing techniques.