Date post: | 12-Apr-2017 |
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Health & Medicine |
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Meruzhan Saghatelyan, MD, Interventional cardiologistNork Marash Medical Center, Yerevan, Armeniawww.nmmc.am
Heavily calcified ostial RCA CTO PCI in a patient with porcelain
aorta
A 46 y/o man referred to our institution for PCI after diagnostic
CAG because of exertional angina.
Cardiovascular risk factors: hypertension and hyperlipidemia, ex-
smoker.
History of lymphoma and chest radiation therapy.
Coronary angiography revealed porcelain aorta and proximal
occlusion of RCA just after a major RV branch, heavy calcification of
RCA ostium and unclear proximal cap.
Normal sinus rhythm without ECG abnormalities.
Mild to moderate LV hypertrophy and preserved LV contractility
without regional wall motion impairment on transthoracic
echocardiography.
Mild aortic stenosis, mild aortic regurgitation and calcified valve
leaflets, mild mitral regurgitation
Normal renal function.
Laboratory tests were normal.
Coronary circulation was of right dominant type.
Gross calcification of aortic root and both coronary ostia.
CTO of proximal RCA after major RV branch without definite
stump.
Heavy calcification around LM ostium but no significant stenosis
in the left system.
Several septal connections were present.
The first procedure was mainly diagnostic to locate the proximal
cap and to understand the anatomy using 6F JR4 SH guide for
RCA and diagnostic JL3.5 cath. for the left.
Occlusion of proximal RCA seemingly just after origin of RV branch
Seems to be right position but very hard for GAIA II
Tip injection from microcatheter
Trying to locate the proximal cap
Suspected separate origin of main RCA and ostial CTO in this projection
Separate and lower located origin of RCA with downward course and ostial RCA
Short and calcified ostial RCA occlusion
Planning retrograde procedure using one of the septal connections
Guide manipulation and engagement of coronary ostia was very
difficult due to small and totally calcified aortic root. Bifemoral
approach with 7F JL 3.5SH guide catheter for the LM and 6F AR1
guide catheter for the RCA ostium.
Retrograde procedure was planned from the beginning.
We located several not so clear connections to proximal PDA from
2nd septal with tip injection in Corsair.
Sion guidewire crossed the collateral and reached distal vessel.
JL 3.5 guide provided very poor back-up, and to advance Corsair
we tried anchoring. Anchoring in distal LAD did not help. Then we
made anchor ballooning in small atrial branch of LCX that gave
much more support and helped to advance Corsair.
Only JL3.5 7F could be engaged in the LM ostium
Tiny but direct septal connections were located with tip injection in 2nd septal
Passing septal connection with Sion
Advancement of Corsair with the anchoring
Trying to orient Gaia II through RCA ostium
Conquest Pro 9 from retrograde and Conquest Pro 12 from antegrade
Antegrade dilatation with 2.0 balloon for reverse CART
Breaking calcified plaque with 2.5 mm NC balloon for reverse CART
Successful reverse CART with 2.5 mm balloon and Conquest Pro
Predilatation with 1.25mm balloon
Predilatation with 2.0mm balloon
Even a small balloon did not cross over the externalized wire
Antegrade wiring and predilatation with NC balloons
Proximal vessel perforation after predilatation
Promus Premier 2.5 x 32 stent deployement
Deployement of the second 2.5 mm DES
Postdilatation with 3.5 mm noncompliant balloon
Checking the Left system
Final result
Final result
• To advance retrograde Corsair in poor back up conditions
anchor ballooning is useful option. Better support was
achieved with anchoring in atrial branch than in apical
LAD to advance Corsair through septal connection.
• Reverse CART is safer than direct retrograde crossing to
recanalize ostial occlusion to avoid aorto-ostial dissection
or loss of major side branch.
• In very calcified lesions we may need more support than
that with externalized wire alone, to advance balloons
and stents.