Case Summary
PCI to LAD via LIMA through the left radial artery. A 6-Fr IM guide was used to engage the LIMA. As a result of severe tortuosity of the LIMA we encountered difficulty in advancing a Sion Blue wire down to the lesion which was distal to the LIMA-LAD anastomosis. We tried a Finecross but failed. We then used a Caravel and a Suoh 3 wire to no avail. Finally we managed to navigate through all of the bends and cross the lesion with a Caravel and a Sion wire. We then used a 6-Fr Guideliner and another Sion buddy wire to deliver a balloon and a stent (Orsiro 2.75×20).
Challenges encountered
Tortuous left subclavian and LIMA.
Equipment
- Finecross
- Caravel
- Guide-liner
- Sion Blue
- Sion
- Suoh 3
Learning Points
Commentary by Dr. Sidney Lo:
The need to do LIMA intervention is uncommon. Engagement may be difficult with either radial, brachial or femoral access due to anatomical factors (eg tortuosity in femoroiliac system or subclavian). One technique may be to use either a IM or BC diagnostic catheter to engage and wire into LIMA and exchange over this to a guide (although the guide may still not sit well). This usually needs an extension wire or a long coronary wire (0.014” and 0.035”). A guide extension (eg a Guide-liner) is a reasonable idea but care is needed as dissection of LIMA ostium is a risk and introduction may require a balloon to facilitate. As there is usually some redundancy in the LIMA graft it is often tortuous – note should be made of the site of the target lesion as the length of interventional equipment may be too short. Ways of overcoming this include cutting the guiding catheter or use manufactured short guides (90cm) and also using access such as brachial artery which is not without risk. A soft, low tip load, torquable guidewire over a microcatheter aids wiring especially if tortuous. No data for rapid exchange over OTW but historically OTW systems were favoured. Good Lesion preparation is mandatory and direct stent should be avoided. Once PCI via the LIMA is undertaken – this vessel is at risk and emergency planning in the event of closure of this vessel should be contemplated as any difficulty in advancing equipment may push guide out and any equipment removal causes re-engagement of guides – care should be taken with the state of LIMA ostium post-PCI and this should be checked and an angiogram taken. Dissection should be managed with stenting. Rotational atherectomy should not be performed in the LIMA as this has a very high risk of dissection and acute closure. Very urgent intervention sometimes on the same day as bypass surgery can be done safely to a newly created LIMA-LAD anatomosis including POBA and stenting. Results from POBA of the LIMA-LAD distal anastomosis has been reasonable in the literature. Commonly there is a size mismatch which may make sizing of stents difficult if anastomosis is stented. If tortuosity limits equipment passage, then shorter lengths and smaller calibre stents should be chosen for flexibility and delivery (also thin strutted stents may have an advantage as in this case). Insitu RIMA Graft intervention is also difficult as it can be hard to engage the ostium on the curve of the innominate artery.
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