Case presentation

A 49-year-old man with no significant past medical history presented to the hospital after a prolonged episode of chest pain associated with nausea and diaphoresis. Initial troponin was only slightly abnormal (0.07 ng/mL) and he was admitted with the diagnosis of a non-ST segment elevation myocardial infarction. He was treated with a beta blocker, nitrates, and low-molecular-weight heparin and referred for cardiac catheterization.

Cardiac catheterization

The culprit lesion involved the right coronary artery. There was a severe stenosis in the midportion of the right coronary artery past an extremely tortuous segment of the artery (Figures 12-1, 12-2, 12-3 and Video 12-1). There was moderate disease in the left anterior descending artery (Figures 12-4, 12-5).

FIGURE 12-1 This is a left anterior oblique projection of the right coronary artery showing a severe stenosis in the midsegment (arrow). There is a severely tortuous segment of the artery proximal to the lesion, with moderate atherosclerotic disease.

FIGURE 12-2 This is a right anterior oblique projection of the right coronary artery showing the severe stenosis in the midsegment (arrow) and marked tortuosity of the artery proximal to the lesion.

FIGURE 12-3 This is a left lateral projection of the right coronary artery showing a severe stenosis in the midsegment (arrow) and marked tortuosity proximal to the lesion.

FIGURE 12-4 Representative angiogram of the left coronary artery in the right anterior oblique projection with caudal angulation.

FIGURE 12-5 Representative angiogram of the left coronary artery in the right anterior oblique projection with cranial angulation, showing moderate disease of the left anterior descending artery (arrows).

Based on the angiogram and the clinical presentation, the patient’s physician decided to proceed with a percutaneous intervention of the right coronary artery. The severe tortuosity of the proximal right coronary concerned the operator and, anticipating difficulty passing wires, balloons, and stents around the tortuous segment, the operator decided to use a supportive guide catheter and engaged the right coronary artery with a 6 French extra-support right guide catheter (Cordis, XBRCA). Procedural anticoagulation was accomplished with a bolus of unfractionated heparin and a double bolus plus infusion of eptifibatide. The operator crossed the lesion with a floppy-tipped, 0.014 inch guidewire. This wire successfully straightened the proximal tortuosity and allowed passage of a 2.5 mm diameter by 15 mm long compliant balloon (Figure 12-6). The operator chose a 3.0 mm diameter by 18 mm long bare-metal stent. Advancing the stent to the desired segment of the artery proved very difficult. Ultimately, this stent was successfully delivered to the lesion (Figure 12-7 and Video 12-2). The post-stent angiogram revealed a new and concerning lesion proximal to the stent. This segment of the artery straightened substantially with the floppy-tipped guidewire and the physician was unsure if the angiographic appearance represented a “pseudolesion” due to straightening of the tortuous segment by the guidewire or if it represented an injury to the artery from the vigorous attempts at passing the stent. The operator decided to pass another 3.0 mm by 18 mm stent, but was unable to advance it to the desired location (Figure 12-8). After positioning an extra-supportive guidewire (Mailman, Boston Scientific) alongside the first wire, and after deeply inserting the guide catheter, the operator successfully delivered this stent. The angiogram obtained after the second stent was placed showed that the additional wire further straightened the artery (Figure 12-9