Treating Difficult Coronary Anatomy

The case shown above comes from a 72 year old man who presented with recurrent angina 6 years following bypass surgery. He is diabetic and hypertensive as well. Angiography showed loss of a the jump Saphenous Vein Graft to the Marginal branch and a tight lesion in the mid LAD. During the diagnostic procedure (performed from the right femoral artery), the origin of the left Internal Mammary artery was very difficult to engage due to excessive Subclavian Tortuosity As shown above, the Internal Mammary Artery (IMA) itself is quire tortuous and redundant.

Two days after successful treatment of the Marginal branch, the patient returned to the lab for revascularization of the mid LAD. A Left Radial approach was used to overcome the tortuosity of the Subclavian artery. The multiple loops and bends in the redundant IMA made wiring the mid LAD lesion very difficult. A 'Buddy Wire' (shown above left) was used to provide support for a second wire and transit system by minimizing dislodgment of the guide while wiring the IMA. Ultimately, a 0.014 CHOICE Extra Support wire was used to traverse the redundant IMA. Passage of a balloon catheter through the IMA was also difficult and required deep seating of the 6F guide approximately one-third down the IMA itself. Because of the redundancy of the IMA, there was very little balloon shaft to work with remaining out of body. Shortening the guide was not necessary however after deep-seating the guide. Only after the balloon was passed into the mid LAD did the IMA straighten out. Once the IMA was straightened out, passage of two s670 Stents into the mid LAD was effortless over the support wire. As expected, multiple pseudolesions were evident in the IMA until the stiff wire was removed at the end of the procedure. This procedure was performed by Drs. Levin and Diamond at Christ Hospital.