Mr. SS

Mr. S S 57-year-old gentleman with type II diabetes mellitus and primary hypertension since 2007. He had anterior STEMI in Aug 2019. Coronary angiography revealed double vessel disease (IRA- LAD and NIRA-RCA). PTCA with DES was performed in LAD (3*23 and 2.75*38). Exercise stress echo in 2020 and 2021 was negative for inducible ischemia. Now he had similar angina for 7 days.

His ECG revealed ST- segment depression in inferior leads. Echocardiography revealed EF of 45% as before with no new RWMA. High sensitivity Troponin T was elevated.

Coronary angiography via right distal trans radial access revealed patent LAD stents while subtotal occlusion of proximal RCA. There were two bends just after the tightest stenosis. There were CC class 2 collateral from first septal but it was jailed with previously implanted stent. 

As the anatomy was complex so AL guide was taken along with another access for contra lateral angio. With the help of corsair micro catheter wire escalation technique with BMW, Pilot 50,Fielder and Gaia 2 failed to cross (including parallel wire method). Rather there was cessation of forward flow. Now retrograde approach with caravel and sionblue wire was started through CC 1 collateral from second septal. Sion entered in to RCA while caravel stuck in septal collateral. Sion retrogradely crossed the tightest lesion. Keeping it as landmark, the ante grade wiring was attempted again but could not succeed. Now the retro grade sion wire was further advanced into ante grade AL guide and it incubated the ante grade corsair microcatheter. The corsair slided over the sion wire across the lesion. Retrograde wire was retrieved while ante grade wire advanced through corsair and over it successful PTCA was performed under IVUS guidance.  So finally, it was tip in method which saved the day.

The proximal RCA lesion in 2019 was angiographically significant but it did respond to medical management and stress test was negative in 2020 and 2021. Usually in ACS we proceed and succeed by ante grade approach. Here as it failed so hybrid approach was opted. The first septal was giving rise to CC 2 collaterals but it was jailed so surfing through second septal with its collaterals was performed. Due to their small size even caravel could not be advanced through, however sion blue wire could cross. Ante grade reattempt again failed by the side of that retro grade sion wire. Now tip in technique was only mean for bailout.