Dr. V. Ravi Sekar  DNB., FNB., 

(Interventional Cardiologist)

 

Introduction : With the wide expansions of horizons in the field of percutaneous coronary interventions (PCI) , we see a lot of patients with previous bypass surgery presenting for native vessel or graft interventions. With the recent advances in devices and pharmacology various complex lesions could be addressed through PCI.

Case History : 66 year old male who is a known diabetic, hypertensive who has undergone coronary artery bypass grafting (CABG ) in 2006 with 3 bypass grafts (LIMA to LAD and SVG to OM) presented with recent onset exertional angina for 4 months duration. 

Echocardiogram showed preserved LV systolic function and TMT was positive for inducible ischemia. Coronary angiogram done showed significant progression of native Triple Vessel Disease with patent bypass grafts. PDA showed significant stenosis near the origin of the vessel, which was at pathway of Retrograde flow from graft to PLV Branch. Hence to make blood flow possible to PLV it was decided to stent the PDA origin.

 

 

Patient was taken up for PCI of PDA. The PCI of the lesion was attempted wiring through femoral approach with 7F multipurpose catheter but failed. After repeated attempts with hydrophilic coated wire, still the lesion could not be crossed. 

Then the lesion was crossed with balloon support with a buddy wire placed in posterolateral branch (PLB) and balloon inflated at low atmospheres.

Subsequently repeated attempts to cross the lesion with complaint balloon failed due to poor support guide.

 

Then a 5F mother and child catheter (Guideliner) was used as an extension of original guide till the proximal bend so that the balloon could be negotiated. 

 

Then the lesion was stented with a short everolimus eluting stent (2.75 x 12  mm) in an similar fashion using the guideliner catheter .Final result showed well deployed stent with TIMI III flow.

 

Conclusion: Adequate guide support is an essential pre-requisite for delivery of interventional materials during coronary angioplasty. Poor guide support can be managed with choosing a proper  supportive guide, using buddy wire  or with balloon entrapment. If all the measures fail guide extension with a guideliner could be a very handy and useful tool for delivery of devices in complex PCI.