Case 159: Manual of PCI - I closed the vessel

A patient presented with NSTEMI and was found to have a severe lesion in the proximal RCA that had shepherd’s crook morphology. The RCA was engaged with an AL1 guide using radial access and the lesion was predilated but guide support was limited and guide and wire position was lost. The RCA was re-engaged with a Hockeystick guide but the RCA became occluded likely due to dissection. A workhorse guidewire could not be advanced to the true lumen. We attempted reentry in the mid and distal RCA using a Stingray balloon without success. IVUS showed a large extraplaque hematoma. We attempted subintimal hematoma aspiration through the Stingray balloon itself but also through a Corsair microcatheter but reentry still failed. Retrograde crossing attempts also failed. Using the STAR technique Gladius Mongo wires were advanced to the right posterolateral and the right PDA. IVUS showed decrease in the size of the hematoma and final reentry attempt with the Stingray was successful using the “stick and drive” technique, followed by stenting and restoration of flow in the RCA.