PERCUTANEOUS CORONARY INTERVENTIONS

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Primary PCI for Calcific RCA

Operators:Assoc. Prof. Mutlu Vural

Bağcılar Education and Research Hospital

Case Summary

A 64-year-old male patient presented with acute inferior MI. The patient has psoriasis with extensive skin involvement and type II diabetes. He’s smoking. No medication except for psoriasis and diabetes treatment. The patient, who had no previous cardiac procedure, applied to the hospital with complaints of abdominal pain and nausea. Acute inferior MI was detected on ECG and was taken to the angiography lab. Moderate narrowing of the proximal and critical stenosis in the LAD were observed (video 1 ). RCA has proximal complete occlusion at the proximal portion and diffuse calcification is noted (video 2).

 

Procedure

A floppy guide wire is passed through the AR-2 into occlusion and intense thrombus was observed (video 3). The 3.0×15 mm balloon did not pass through and 1.25 balloon was taken (video 4). Then the 3.0×15 ball was passed (video 5). Critical stenosis appeared after mid-section after current flow (video 6). The balloon was pushed but not passed (video 7). A new 2.0 passed the new balloon lesion but it is burst. Another 2.0×10 new balloon was taken (video 8). However, the 4.0×32 mm stent did not progress from this point. I wanted to replace the wire with a extrasupport wire. We could not find Corsair for this, beyond another microcatheter trap balloon did not pass. Without the trap, when the microcatheter came back, we lost the wire when the microcatheter was withdrawn. The first stenosis area of ​​the patient became total occlusion. When the patient moved, sheat was lost. If sheath was entered again, AL_1 was 7F and 6F was preferred. With Whisper Extrasupport, the first stenosis was passed with some difficulty. Wire down towards to the PLA was advanced. In the new strategy, a 3.0×15 balloon was deployed proximal and then used as an anchor distal to advance the guideliner (video 9). After implantation of 4.0×32 (video 10, video 11,video 12,video 13,video 14),  and a 4.0×37  (video 15, video 16, video 17, video 18); a 4.5×24 (video 19) stents were finally placed. At the last stage, the stent balloon did not deflated completely (video 20). The guideliner and balloon were taken and a new 4.5×15 balloon was introduced to optimize the stent and distal to the stent (video 21, video 22). The result was satisfactory (video 23, video 24).

Conclusions

  1. Microcatheter advance without trap balloon is not advised, (8F guide catheter should be preferred).
  2. Microcatheter with thin diameter should be provided.
  3. In such a case, a guideliner should first be preferred.
  4. Techniques such as pin pon method should be considered to prevent wire lost.
  5. It should be kept in mind that calcific lesions always have a potential to make a surprise.

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Kalsifik Lezyonlar