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Stenting for Heavily Calcified and Tortuous Distal Lesion at Right Coronary Artery Using 5 in 7 French Guiding Catheter Technique
- Operator: Seung-Jung Park, MD

Case presentation

A 73-year old man was admitted with effort chest pain for 6 months. He underwent stents placement at mid-potion of the left anterior descending (LAD) artery and distal portion of left circumflex (LCX) artery. His coronary risk factor was hypertension. Echocardiography showed posterolateral and basal inferior wall akinesia with normal left ventricular contractility (ejection fraction 55%).

Baseline coronary angiography

The stent in mid-LAD was patent, but, the stent in distal LCX was totally occluded (Figure 1). The right coronary artery (RCA) angiogram revealed diffuse narrowing with heavy calcification and marked tortuosity (Figure 2, Figure 3).

Procedure

A 7Fr sheath was inserted into the right femoral artery, and the RCA was engaged with a 7Fr JR 4 guiding catheter. A 0.014 inch Floppy soft guidewire was inserted into the RCA, and the lesions were dilated sequentially with a 2.5 x 20 mm Tempest balloon (Figure 4, Figure 5, Figure 6). After predilation, we tried to introduce a 3.0 x 23 mm Cypher stent in mid-RCA, but, the stent could not pass the tortuous and calcified RCA. So, we introduced 5 Fr straight Heartrail guiding catheter (Terumo Corp) into the mid-RCA through the lumen of 7 Fr JR 4 guiding catheter. With a strong back up force of this technique, the stent was successfully delivered deep into the RCA (Figure 7). A 3.0 x 23 (16 atm / 3.21 mm), 3.5 x 23 (16 atm / 3.72 mm) and a 3.5 x 33 mm (16 atm / 3.72 mm) Cypher stents were deployed sequentially from distal to proximal RCA (Figure 8, Figure 9). The final angiogram showed successful findings (Figure 10, Figure 11).

Take home message

We experienced that this deep engagement technique enables the guiding system approach closer to target lesion.

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