Overcoming Excessive Tortuosity by Choosing the Appropriate Equipment

The case shown above illustrates coronary stenting in highly complex coronary anatomy. The patient is an elderly gentleman who presented to Weiss Hospital with Class III angina despite very aggressive medical management. Diagnostic angiography (performed by Dr. Gonzalez ) demonstrated a tight stenosis in the mid portion of this extremely tortuous right coronary artery with mild disease in the left coronary arteries. Initial attempts to cross the lesion with BMW, Balance, and HTF wires through a AR-1 guide were unsuccessful. There was too much friction and resistance to wire movement and even use of a Transit delivery catheter was unsuccessful. The guide and wire were then removed. Then, using a 6F AL-1 guide (which provided excellent back-up support), the lesion was successfully wired with a lubricious CHOICE PT extra support 300 cm wire. Once the stiff wire was placed into the distal portion of the vessel, multiple pseudo-lesions were evident. Nonetheless, the artery straightened out considerably allowing rather easy tracking of a Ranger balloon to the target lesion. Following balloon removal, the lesion was stented using a 3.5mm Medtronic s670 stent (after another type of stent could not be advanced to the lesion). Movement of the stent to the target area was effortless - most likely due to both the excellent guide support and stiff guide wire. The stent was post dilated to high pressure with a 3.75 mm balloon. Pseudo-lesions persisted until the wire was completely removed from the artery. The patient left the lab pain free with an excellent angiographic result. The interventional procedure was performed by Drs. Cohen and Levin and it was supported by infusion of Abciximab (Reopro).