Case presentation

A 61-year-old woman with hypertension and a history of heavy tobacco abuse developed typical exertional angina 3 months prior to her presentation. Symptoms occurred during moderate exertion and resolved with rest. Medical therapy with beta-blockade and long-acting nitrates temporarily improved her symptoms, but she continued to report lifestyle-limiting angina and underwent an exercise stress test. During this test, she exercised for 7 minutes and developed chest discomfort associated with 1 to 2 mm downsloping ST-segment depression. Perfusion scintigraphy identified a moderate-sized inferolateral reversible defect. She was referred for catheterization.

Cardiac catheterization

Ventriculography demonstrated moderate hypokinesis of the inferior wall, but global function was normal with an estimated ejection fraction of 60%. The right coronary artery was completely occluded and the duration of the occlusion could not be precisely determined (Figure 36-1 and Video 36-1). In the left coronary artery, a severe stenosis was identified in the midsegment of the left circumflex artery (Figure 36-2 and Video 36-2), and a stenosis of at least moderate severity was seen in the midsegment of the left anterior descending artery (Figure 36-3 and Video 36-3). The presence of well-developed left to right collaterals and the duration of symptoms suggested that the right coronary artery was chronically occluded and at least 3 months old.

FIGURE 36-1 This is an LAO image of the right coronary artery demonstrating total occlusion.

FIGURE 36-2 A severe stenosis was present in the left circumflex artery (arrow).

FIGURE 36-3 This is an RAO image with cranial angulation of the left coronary artery demonstrating a moderate stenosis of the LAD (arrow) and extensive collateral circulation to the distal right coronary artery (double arrow).

The patient remained on the catheterization table and the findings were explained to her. After a lengthy discussion regarding the options of bypass surgery versus multivessel percutaneous coronary intervention, the patient chose percutaneous revascularization with the understanding that, if the operator could not successfully treat the chronically occluded right coronary artery, surgical revascularization would be necessary.

With this strategy in mind, the operator began with the right coronary artery. Procedural anticoagulation was accomplished with bivalirudin; the patient had already received pretreatment with 300 mg of clopidogrel the night before the procedure. After engaging a 6 French right Judkins guide catheter, the operator loaded a stiff-tipped 0.014 inch guidewire (Miracle Bros, 3, Asahi) into the lumen of a 2.5 mm diameter by 15 mm long, “over-the-wire,” compliant balloon catheter. The stiff-tipped guidewire easily crossed the occlusion and was advanced into the distal right coronary artery (Figure 36-4). The “over-the-wire” balloon was advanced distally and the stiff-tipped wire was removed and replaced by a floppy-tipped guidewire. Patency was restored after performing balloon angioplasty with the 2.5 mm balloon; however, the artery appeared diffusely diseased distally with an extensive dissection in the midsection (Figure 36-5 and Video 36-4). Multiple everolimus-eluting stents were placed, ranging in diameter from 2.5 mm distally to 3.5 mm proximally, covering 98 mm of length. The proximal and midsegments were postdilated with a 4.0 mm noncompliant balloon and an excellent final angiographic result was obtained (Figure 36-6 and Video 36-5).

FIGURE 36-4 A stiff-tipped angioplasty guidewire was used to cross the totally occluded segment of the right coronary artery.

FIGURE 36-5 Result after balloon angioplasty; there is extensive dissection and distal disease observed (arrow).