This was a 38 years old gentleman who suffered acute ST segment elevation inferior wall MI on 11/6/2004. He came to hospital on 25/6/2004 because of persistent chest pain. ECG showed Q in III and a VF with persistent ST segment depression in V1- V4.
First angioplasty was performed on 25/6/ 2004 with one of our interventional cardiologist and revealed a right dominant system with a total occlusion of the distal right coronary artery just after the origin of the posterior descending artery. There was also left to right collateral to the distal right coronary artery. The angioplasty was performed with BMW Universal GW which was unable to cross the lesion. The operator used the angioplasty balloon to stiff the GW which resulted in dissection with false lumen and the procedure was called off.

The patient was worsening exertional chest pain despite full medication treatment so second angioplasty was performed on 14/9/2004. The second operator used the Cross- it XT 200 which was failed to cross the chronic total occlusion and the Cross – it XT 300 which resulted in another dissection with false tract and he was again put on medical treatment.

The patient still had severe limited angina and was referred to me and was scheduled for another angioplasty on 14/2/2005, five months after last angioplasty and 8 months after the initial occlusion. Giving the history of difficult angioplasty with twice dissection, I decided to use the hydrophilic slippery GW with slightly stiffness so I chose the Pilot 150 GW (Figure 1) and pre-loaded in the over the wire Voyager balloon (Figure 2). I decided not to stiff the wire with the balloon and let the wire do its job. (We had to pre-loaded it because we used the 190 cm. GW in over the wire balloon) The Pilot 150 GW was successfully cross the lesion but the Voyager balloon was unable to cross the whole length of the lesion. (Figure 3) So the first dilation was made at the proximal portion of the lesion and the second Cross –it XT 200 GW was crossed the lesion (Figure 4) to facilitated the passage of the balloon. (Buddy wire with the railroad technique) The balloon was successfully crossed the lesion (Figure 5) and the dilation was made with 1.5, 2.0 and 2.5 mm. balloon. (Figure 6, Figure 7). Finally the 2.75 x23 mm ML Zeta stent was deployed up to 12 atm (Figure 8) resulted in excellent angioplasty result. (Figure 9)

The patient remained symptom free and had following angiography on 9/6/2005 (3 1/2 months after PCI) which revealed excellent patency of the stent.