Author + information
- Johan Senihardja1,
- Bambang Budiono2,
- Benny Mulyanto Setiadi1,
- Agnes Lucia Panda1,
- Janry Anton Pangemanan1,
- Rizki Francis Pandelaki1,
- Monique Priscilla Fransiska Rotty1,
- Soetandar Widjaja1 and
- Iman Suhartono1
Patient initials or identifier number
Relevant clinical history and physical exam
A 51 years-old male admitted with complaining chest pain for the last one week. He felt a tight sensation at his chest while doing light activity such as walking for short distance. He already received the medical therapy. Two months earlier, patient was hospitalized due to the same complaint and treated as unstable angina pectoris. He had history of hypertension for long time period. Physical examination was within normal limit.
Relevant test results prior to catheterization
ECG showed that there was Q pathology at inferior lead suggesting there is old myocardium infraction at that region.
Relevant catheterization findings
Diagnostic coronary angiogram showed that there were stenosis about 60% at proximal LAD, stenosis 90% at proximal LCx, chronic total occlusion (CTO) at mid LCx. For RCA, there was ostial lesion and CTO from proximal RCA.
PCI to RCA was done using trans radial technique. A 6 Fr TR 4.0 guide catheter was inserted to engage ostial right coronary. A 0.014“ Runthrough Hypercoat wire was inserted into RCA. After successful crossing, the lesion, a 2.0 x 20 mm Maverick balloon was used to pre-dilate the proximal to mid RCA at 6 atm. After serial pre-dilatation, there was a difficulty in advancing 3,0 x 38 mm CRE8 stent through the lesion. Not just once, but a second attempt still failed. Another 0.014” Run through hyper coat wire was inserted for side branch anchoring technique. Additional pre-dilatation was then performed, but the stent still remained unable to cross the lesion. The side wire anchoring was removed and then was advanced to the distal RCA as buddy wire. This attempt was failed to deliver stent. Eventually, the operator chose to try distal anchoring balloon to overcome the difficulty. While stent was positioned at tip of the catheter, a 2.0 x 20 mm Maverick balloon was advanced to distal RCA and inflated at 4 atm. Re-advanced the stent was successful, and then distal balloon was deflated and removed. The lesion was treated with 3.0 x 38 mm CRE8 stent. The final angiographic result was very good with TIMI 3 Flow.
Dealing in CTO is challenging, therefore well prepared strategies is needed. Doing PCI in CTO with ostial lesion could be more challenging since we will not have a good supporting catheter. After wire has crossed the lesion, there could be another problem, such as delivering long stent through the lesion. We should never force in advancing the stent, it may cause further complications. Knowing various technique in delivery long stent through the lesion is mandatory to prevent further complication or “failed PCI”.