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Saturday 1415 – Saghatelyan - Patient with porcelain aorta
- 1. Meruzhan Saghatelyan, MD, Interventional cardiologist Nork Marash Medical Center, Yerevan, Armenia www.nmmc.am
- 2. Heavily calcified ostial RCA CTO PCI in a patient with porcelain aorta
- 3. A 46 y/o man referred to our institution for PCI after diagnostic CAG because of exertional angina. Cardiovascular risk factors: hypertension and hyperlipidemia, ex- smoker. History of lymphoma and chest radiation therapy. Coronary angiography revealed porcelain aorta and proximal occlusion of RCA just after a major RV branch, heavy calcification of RCA ostium and unclear proximal cap.
- 4. Normal sinus rhythm without ECG abnormalities. Mild to moderate LV hypertrophy and preserved LV contractility without regional wall motion impairment on transthoracic echocardiography. Mild aortic stenosis, mild aortic regurgitation and calcified valve leaflets, mild mitral regurgitation Normal renal function. Laboratory tests were normal.
- 5. Coronary circulation was of right dominant type. Gross calcification of aortic root and both coronary ostia. CTO of proximal RCA after major RV branch without definite stump. Heavy calcification around LM ostium but no significant stenosis in the left system. Several septal connections were present. The first procedure was mainly diagnostic to locate the proximal cap and to understand the anatomy using 6F JR4 SH guide for RCA and diagnostic JL3.5 cath. for the left.
- 7. Occlusion of proximal RCA seemingly just after origin of RV branch
- 8. Seems to be right position but very hard for GAIA II
- 9. Tip injection from microcatheter
- 10. Trying to locate the proximal cap
- 11. Suspected separate origin of main RCA and ostial CTO in this projection
- 12. Separate and lower located origin of RCA with downward course and ostial RCA
- 13. Short and calcified ostial RCA occlusion
- 14. Planning retrograde procedure using one of the septal connections
- 15. Guide manipulation and engagement of coronary ostia was very difficult due to small and totally calcified aortic root. Bifemoral approach with 7F JL 3.5SH guide catheter for the LM and 6F AR1 guide catheter for the RCA ostium. Retrograde procedure was planned from the beginning. We located several not so clear connections to proximal PDA from 2nd septal with tip injection in Corsair. Sion guidewire crossed the collateral and reached distal vessel. JL 3.5 guide provided very poor back-up, and to advance Corsair we tried anchoring. Anchoring in distal LAD did not help. Then we made anchor ballooning in small atrial branch of LCX that gave much more support and helped to advance Corsair.
- 16. Only JL3.5 7F could be engaged in the LM ostium
- 17. Tiny but direct septal connections were located with tip injection in 2nd septal
- 18. Passing septal connection with Sion
- 19. Advancement of Corsair with the anchoring
- 20. Trying to orient Gaia II through RCA ostium
- 21. Conquest Pro 9 from retrograde and Conquest Pro 12 from antegrade
- 22. Antegrade dilatation with 2.0 balloon for reverse CART
- 23. Breaking calcified plaque with 2.5 mm NC balloon for reverse CART
- 24. Successful reverse CART with 2.5 mm balloon and Conquest Pro
- 26. Predilatation with 1.25mm balloon
- 27. Predilatation with 2.0mm balloon
- 28. Even a small balloon did not cross over the externalized wire
- 30. Antegrade wiring and predilatation with NC balloons
- 32. Proximal vessel perforation after predilatation
- 33. Promus Premier 2.5 x 32 stent deployement
- 34. Deployement of the second 2.5 mm DES
- 35. Postdilatation with 3.5 mm noncompliant balloon
- 36. Checking the Left system
- 37. Final result
- 38. Final result
- 40. • To advance retrograde Corsair in poor back up conditions anchor ballooning is useful option. Better support was achieved with anchoring in atrial branch than in apical LAD to advance Corsair through septal connection. • Reverse CART is safer than direct retrograde crossing to recanalize ostial occlusion to avoid aorto-ostial dissection or loss of major side branch. • In very calcified lesions we may need more support than that with externalized wire alone, to advance balloons and stents.