The RCA Challenge
by Dr. Salman Arain
šš¼This is the case that almost got away. 58 year old man with a failed attempt by the referring MD. He has severe ischemia in the inferolateral region. He does not have LAD or left main disease, so not an upfront CABG candidate.
But before I do, let me just lay out some initial considerations:
- Guide support
- Crossing the tortuosity (or tortuosities!)
- Prevention of spasm +/- accordion effect
- Lesion prep – given the nodular calcium appearance.
I felt that a soft tipped hydrophilic wire was essential to start. Also, up front guide extensionā¦
There is a 2 mm balloon, partially extending out of the GL tip. It is inflated to 4 atm. Both balloon and GL are advanced together. This is not my attempt. But my commentary is that the operator has good support but his choice of a microcatheter (MC) could have been better. Braided MCs perform better than OTW balloons and unbraided MCs.
Also, the wire should ideally be a highly torquable wire with an appropriate tip. Most workhorse wires donāt have adequate support and/or the appropriate tip – hydrophilic tapered would be ideal.
This is our first attempt – we used multiple wires and tip shapes. Fielder XT, Sion Black, Fighter, and Gladius Mongo.You can see that I am using the Luge as a marker wire. I also have a dual lumen catheter so that the wires donāt interact (with the bonus advantage of support).
Anyway, in the interest of time and not to bore the audience with the drawn out style (which is how I teach!), we decided to take another hi-res view of the lesion. Turns out it is very complex because it comes off in a retroflexed manner, there plaque proximal to it which deflects the MC, and there is a hinge point which makes the lesion even tighter in systole!!! I have deliberately slowed it down here. So, last question. What do you do here? How to solve this twist in the tail?!
What we ended up doing (with luck as much as intention) is creating a ābiplanar curveā aka a spiral tip. It bent both downwards and to the side. This allowed us to ācork screwā the wire (Mongo) into the PDA.
But, to put it in perspective, what looks like an obvious solution (now) took years of doing complex cases to achieve. And hundreds if not thousands of cases
Final thoughts. There are three ways to use a balloon to advance a GL.
Anchoring. Best for short distances with few bends. You can do it repeatedly as you go down the vessel.
Inch worming. This is where you deflate the balloon and advance the GL over it. Best for heavily calcified arteries and/or tracking within stents.
- BAT. Best for arteries with extreme tortuosity, which are otherwise patent proximately. Or to go down open grafts.
Thank you but we tried all combinations I could think of. With all types of wire tips. Even a Carlino to make a channel and a knuckle. Nothing worked – primarily because the lesion is foreshortened in our initial working view and because the āhingeā at the PDA origin changes the orientation of the opening with every heart beat. A dynamic stenosis! BTW, the wires we used included a Fielder XT, Fighter, Mongo, Sion Black, and a Gaia 2. The bi-planar tip is on the Mongo.
And not with the usual curve added to the pre-shaped tip. Only after we gave it a sideways second curve. You can see it unfold a bit, before we were able to advance it across the stenosis.
Prof. Salman Arain
Permission to reproduce above obtained from Dr. Salman Arain on Nov 27 2023
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