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Successful Cypher Stent Implantation With Deep Seating of 6 French Guiding Catheter in Very Tortuous Right Coronary Artery
- Operator: Seung-Jung Park, MD
Case presentation
A 60 year-old man was admitted with stable angina 6 months ago. A Taxus stent (3.5 x 20 mm) and a Driver stent (3.0 x 15 mm) were implanted without overlapping at the right coronary artery (RCA) lesion. His coronary risk factors were hyperlipidemia and hypertension. Baseline ECG was normal and echocardiography showed normal LV ejection fraction of 56% and concentric LVH.
Follow-up angiogram at 6 months showed tight stenosis at the gap between the two implanted stents (Figure 1). Because the RCA looked very tortuous, calcific, and rigid, we initially engaged the lesion with a 7 Fr left Amplatz guiding catheter for a good back-up support. However, coaxial alignment was not good (Figure 2). Thus, we changed the guiding catheter with a Hockey stick (Figure 3). After advancement of a Neos guidewire, predilation was performed with a Black Hawk balloon (3.0 x 20mm) (Figure 4, Figure 5). Although we tried to insert a Cypher stent (3.5 x 23mm) to the target lesion, the stent could not pass the tortuous RCA. Therefore, we intended to engage the RCA with the technique of deep coronary intubation with a 6 Fr Judkins right guiding catheter with a 3.5cm curve (Figure 6). After deep seating of a 6 Fr guiding catheter in the middle RCA, we successfully delivered a Cypher stent (3.5 x 23mm) and deployed it in the target lesion (Figure 7). Final angiograms showed a successful result (Figure 8, Figure 9).
Jingyu Hang2005-03-20
Delivering long DES in a tortuous RCA is always a challenge. The result of this case is optimal,but the course is tough.
javed ali khan2005-03-25
It was very challenging but successfully done work. congrats to the operator. I want to know which guide wire was used ? javed a. khan
Jorge Mayol2005-03-26
In challenging cases because of tortuous anatomy or bad coaxial alignment of the guiding catheter, the Cypher Stent works better than the Taxus. That´s one of our indication of Cypher over Taxus. By the way the most flexible and deliverable Bare Stent we´ve used is the JoStent. Sometimes in stuff casses, when the Cypher didn´t work we finnaly deployed one of this.
deep-seating or deep-throating of rca is certainally not for novices , it can be traumatic and may cause unmanagable dissection . however this particular case is excellent!
Deshpande Shantanu2005-03-27
As this RCA origin is looking down or its oriented downwards i always thought a hockey stick will be an initial choice than Amplatz one. Eventhough there is risk of dissection this maneuver of deep throating the catheter is really useful in difficult cases.Exceelent case !
Dr.Pramod Jaiswal2005-03-28
Excellent case, done with perfection. Congratulation. A simpler, safer, alternative strategy is to use an extra-support wire as the first wire, and a floppy wire as a buddy wire. Passing the stent on the floppy wire works really well as the stent tracks over a more flexible floppy wire without hitting against any sharp bends in the tortuous vessel, and the extra-support wire gives enough support to the guiding catheter and avoids kicking back of guiding. Try it once. It really works. Dr. Pramod Jaiswal.
Young-Hak Kim2005-04-01
In this procedure, we used a conventional intermediate guidewire. However, in some cases, steeper guidewires, such as extrasupport wire, have been useful.
Marcelo Ribeiro2005-04-22
Congratulations for the superb result.I wonder if you were able to exchange the guiding catheter without losing position, and how did you choose the length of the stent?
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