Case presentation. 81 year old WF with Hx DM and HTN was brought by MICU from Newark airport with acute inferoposterior and RV MI, complicated by shock and 3° AV block. Due to numerous events of VT and VF alternating with 3° AV block the patient was supported with IABP and transvenous pacing prior to coronary angiography. SBP dropped to 30 mmHg and treated with boluses of noradrenaline and adrenaline surperimposed on dopamine drip (10 mcg/kg/min).

Cardiac catheterisation showed a proximal RCA occlusion. Emergency PCI was attempted during CPR, with the use of 6F LIMA-curve guiding catheter and Hi-torque Balance 0,014” guidewire. The wire crossed two lesions in the proximal and mid RCA. During direct stenting (Cypher 3/18 mm) the patient made a violent move causing retraction of the guiding catheter, guidewire and stent. The stent was sub-optimally deployed into the ostium of the RCA protruding > 5mm into the Aorta, and under-expanded in its proximal portion. We attempted to engage the guiding catheter into the RCA but the catheter was sitting underneath the protruding stent. One minute later RCA closed and there were different options: -snare the stent, but the stent was too deployed, -rewire the RCA via the proximal stent orifice or via-side of protruding portion of the stent, -“go-under” (underneath stent struts) create a new lumen by crushing and restenting.

Attempts of “civilised rewiring” or via the side of protruding portion of the stent were unsuccessful. Reluctantly we explored the “uncivilised” option. Two Whisper wires advanced underneath the stent struts into RCA; then sequential tunnelling and crushing by Maverick 2/15 mm balloon and 3/15 mm was performed, yielding a new “stent ready” tunnel. Liberté (3/20) was advanced underneath the crushed stent, positioned and deployed.

“Buddy wire” left under the newly deployed stent was transformed into a “buried wire”. This “buried wire” was anchored by the deployed stent and greatly enhanced guiding catheter support for the challenging distal stenting. A second Liberté (2.75/32 MM) was advanced, positioned and deployed. Hospital course was uneventful and patient was discharged home 4 days later. Discussion. Rarely is wiring through the stent orifice and lumen accomplished. In those situations, crushing the stent (in its partial or full length) by sequential balloon dilatations and deployment of a second stent will yield a new stent lumen with a crushed stent underneath. This “last resort method” should be reserved for emergencies after conventional methods have failed, since there is insufficient safety data regarding the consequences of crushing a coronary stent under another coronary stent.

A few reports describe crushing an embolised or under-deployed stent under another coronary stent or covered stent with favourable outcomes. We have used this method in former 3 cases of embolised undeployed stent, without any early or late adverse events.

The “buried wire method” is a good way to enhance guiding catheter support for challenging multiple-lesion stenting executed from proximal to distal. Click here to view the case

Hélène Routledge, from Massy France, wins second prize for her case presentation of “Use of a delectable tip catheter for complex interventions beyond insertion of bypass grafts”.

The patient was a 73 years old man, diabetic, hypertensive, smoker who had get a CABG in 2001 for 3 VD (LIMA-LAD, RIMA-OM1, SVG-PDA). In 2007, he suffered of instable angina. The angiogram showed a new proximal lesion on the PDA compromising a large PLA.

The strategy chosen was to use a 6F MPA in SVG ostium with a Whisper wire because of the ostial occlusion of native RCA and the extreme angulation before and after the lesion. A Venture catheter actively deflected > 90° had been engaged in the ostium of PDA. Whisper wire had been passed via Venture Catheter into PDA and distal RCA. A second Whisper wire had been steered into PLA. After a failure to reach lesion with balloon, Whisper wire in PLA was exchanged for BHW.

With support of 2 BHWs Endeavour 2,the 75/14 navigates the bend and is positioned across the lesion and deployed. For Hélène Rotledge, “the Venture steerable tip catheter is a useful tool for guidewire negotiation of extremely angulated and tortuous lesions beyond the insertion of bypass grafts”. Click here to view the case

Manjeet Juneja from The Prince Charles Hospital in Brisbane (Australia) wins the third best clinical case presentation award for “Percutaneous closure of an Ascending Aorta pseudo-aneurysm with an Amplatzer septal occluder”. Patricia, the patient, was suffering of a saccular pseudoaneuvrysm measuring 7,1X5,1 cm with a neck of 1,3X1,1 cm.
“Because we needed to act fast, the options were a surgical repair for the high risk patient (age, diabetes, BMI 49, chronic renal failure and peripheral neuropathy), or percutaneous intervention. We discussed the patient’s related considerations: access in a view of very high BMI and the need for large sheats, need to limit volume contrast, need for TEE and intra cardiac echo and radiation concerns. At the same time we analyse technical considerations such as choice of catheter and sizing of device”. Other considerations – off label use, risk of rupture, dislodgement of thrombus and urgency versus emergency – were discussed.
At the beginning, the percutaneous intervention started easily. But then problems with deployment appeared: the RA disc tended to prolapse across the neck of the pseudoaneuvrysm thus requiring repositioning. The angiographic result was finally good and at 10 months the patients is in good shape.
For Majeet Juneja, “following the early success shown in the previous papers, our case now shows that percutaneous closure is a safe and effective strategy with good intermediate term outcome. It can obviate the risk associated with surgery”. Click here to view the case