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Stentings for Tight Stenosis with Very Heavy Calcification and Tortuosity in Right Coronary Artery

- Operator: Myeong-Ki Hong, MD, Young-Hak Kim, MD, Korea
Case presentation
A 60-year old male patient was admitted with resting chest pain for 3 months. He had suffered from ST elevation myocardial infarction 6 years ago and undergone stenting at the middle left anterior descending artery (LAD). His coronary risk factors were hypertension and hypercholesterolemia. Baseline ECG showed T inversion in V2 - V6. Echocardiography showed apical akinesia and newly developed basal inferior akinesia with normal LV systolic function (57% of ejection fraction).
Baseline angiography
The stent at the middle LAD was patent. (Figure 1). Right angiogram revealed tight stenoses with heavy calcification at the proximal and middle segment of the right coronary artery (RCA). (Figure 2, Figure 3).
Procedures
A 7F sheath was inserted through the right femoral artery and the RCA was engaged with a 7F Judkins guiding catheter. A 0.014 inch NEO’s Rinato wire was inserted into the RCA, and the lesions were dilated with a 2.5mm x 14mm Maestro balloon at 14atm.(Figure 4, Figure 5) Although, we tried to deliver a 3.5mm x 20mm Taxus stent to the middle RCA lesion, it was failed. Therefore, we exchange the guiding catheter with a 7F Hockey-stick for better guiding support.(Figure 6) In addition, we changed the pre-existing wire with a 0.014 inch BMW wire and redilated the middle RCA lesion with a same balloon.(Figure 7) And then the proximal RCA was stented first with a 3.5mm x 20mm Taxus stent due to failure of stent delivery to the middle RCA lesion.(Figure 8). Because reattempt of stent delivery into the middle RCA was not succeeded, another 0.014 inch Choice PT wire was inserted. After the middle RCA was repeatedly dilated with a conventional balloon, a 3.0mm x 15mm Driver stent was successfully crossed and deployed in the middle RCA (Figure 9). After post-dilatation in the proximal and middle RCA stent, we achieved an optimal result.(Figure 10, Figure 11)
Yun-Dai Chen2004-05-16
Yun-Dai Chen2004-05-16
Yong He2004-05-21
Good job!Dr Hong.But could you tell me the reason for guidewire chosing,first NEO's Renato,then BMW and the final one Choice PT.Another question ,had you ever tried a short stent,such as Taxus 3.0/16mm or Driver 3.0/15mm for the middle lesion before you stent the proximal segment,after all,the possibility of failing to cross the stented proximal RCA exist.Thank you.
Young-Hak Kim2004-05-28
Although we tried to put shorter stents like Taxus and Diver into the middle RCA, we could not. Therefore, we inserted the wires with different characteristics to facilitate stent delivery. In tortous or calcified lesions, multiple guidewire position often makes stent delivery much easier than conventional stenting technique.
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