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TCTAP C-130 Retrieval of Broken Diagnostic Coronary Catheter Using Angioplasty Balloon
S250
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
withdrawn into the guiding catheter with traction of both wires andsuccessfully brought out and the small piece was also retrieved.
Case Summary. Dealing with heavy calcified lesion is challenging and needs proper technique to overcome. Sometimes we may need Mother and Child system in dealing the difficulty to deliver the stent. Catheter induced coronary dissection during PCI is a rare complication but life threatening especially in unprotected coronary artery which supply other disease vessel. Manipulation of child catheter may create dissection. Careful selection and manipulation of catheters and paying more attention to high-risk lesion are important to avoid such complication. Prompt treatment with conventional stenting for coronary dissection is essential and lifesaving. TCTAP C-130 Retrieval of Broken Diagnostic Coronary Catheter Using Angioplasty Balloon Saurabh Goel1 1 Cumballa Hill Hospital, India [CLINICAL INFORMATION] Patient initials or identifier number. SA Relevant clinical history and physical exam. 50 year old male patient, hypertensive since 3 years, non-diabetic, nonsmoker recent history of hospitalization 8 days back for acute chest pain and treatment as acute inferior myocardial infarction. He was thrombolysed with tenecteplase pulse 66/min bp 150/86 cvs - nad rs – clear. Relevant catheterization findings. Coronary angiography was done from right femoral access. The LAD showed 50% proximal lesion and LCxwas dominant and normal. The RCA was arising anamously from high midlineorigin and could not be cannulated despite using several standard catheters. Anattempt was made using al1 catheter as it was thought that it may reach theorigin. But during manipulation the distal tip of about 4cm broke from theshaft and migrated to upper thoracic aorta. [INTERVENTIONAL MANAGEMENT] Procedural step. Retreival of the catheter piece was attempted using available loop basket snare but it unsuccessful.Right angle loop snare was not available at that time in the cath lab. Punchbiopsy forcep was then used which gripped the shaft of the catheter piece andthe distal curved part of the amplatz catheter was removed. During themanipulation, a small 1.5 cm part of the shaft proximal to the point ofattachment of the forcep broke and migrated into a branch of the femoralartery. The left femoral artery was then punctured and through a cross over sheath. A multipurpose guiding was placed near the catheterpiece. Two coronary guide wires (0.0014) were passed through the lumen of thecatheter piece. On one of the wires a 2x10 mm angioplasty balloon was placed atthe centre of the catheter piece. It was inflated to 16 atm and the piece wassecured and
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Case Summary. A broken catheter piece in the arterial system is nightmare in the cath lab and requires out of the box thinking for retreival. In this case the broken piece was partly removedwith a punch biopsy forcep. Another smaller piece migrated to a smaller distalartery where thrombus formation was possible and surgical removal would havebeen very difficult. An innovative strategy of two coronary guide wires and angioplastyballoon inflated in the lumen of the piece was used to successfully remove thebroken catheter. TCTAP C-131 Iatrogenic Dissection of Right Coronary Artery Concomitant with Antegrade Aortic Dissection Chun-Yen Chiang,1 Po-Sen Huang,1 Chen-Chuan Cheng,1 Po-Ming Ku1 Chi-Mei Medical Center, Taiwan
1
[CLINICAL INFORMATION] Patient initials or identifier number. 10854785 Mrs. Li Relevant clinical history and physical exam. This 71 years old female with obese figure suffered from crescent chest tightness since yesterday. She has the medical history of hypertension and diabetes mellitus with poor control (HbA1C 9.0%). She reported the discomfort was dull pain, persisted for more than 10minutes and accompanied diaphoresis and dyspnea but no radiation. This angina was partially relieved by resting and nitroglycerin 1 tab sublinqual use. Physical exam revealed no heart murmur or rales over chest. Relevant test results prior to catheterization. No dynamic elevation of cardiac enzyme in 4 hours was noticed. Serial ECG showed atrial fibrillation with moderate ventricular response and no2015 obvious or significant ST-T change was noted. Reference
hs-Troponin<26.2 pg/mL
CK-Total29-168
CK-MBmass <3.4 ng/mL
U/L 2015/09/06 ER
hs-TroponinI[3.40 pg/mL]
CK-Total[44U/L]
CK-MBmass[0.7 ng/mL]
4 hours later
hs-TroponinI[4.20 pg/mL]
CK-Total[49U/L]
CK-MBmass[0.8 ng/mL]
S251
Relevant catheterization findings. Post-Cath Diagnosis: CAD (1-V-D) over RCA with iatrogenic spiral dissection extending to ascending aorta. Engaging catheter: RCA: JR4.0; LCA: JL3.5 Dominant: RCA LM: Normal LAD: Normal LCX: Normal RCA: Spiraldissection involved aortic root with contrast stasis and RCA-ostiun to RCA-D with TIMI II when engaged into RCA-ostium by guiding catheter of JR4(Boston). The 12-leadECG showed ST elevation and the patient felt chest pain with radiation to back. Meanwhile, BP 150/84mmHg, HR: 65 bpm and SPO2: 95%. [INTERVENTIONAL MANAGEMENT] Procedural step. Due to bradycardia and hypotension, we deposited temporary pacemaker and the condition became relatively stable. Later, we finished left coronary angiography, which showed no lesion. Under the guiding catheter of JR4.0, 6Fr(Bosten) via left radial approach, the first guidewire(GW) of Fielder(Asahi) cross RCA-lesion smoothly and then we put the IVUS into RCA-D and showed GW into false lumen from RCA-O to RCA-D. We decided to put another GW of Filder into RCA again. Finally, IVUS showed second GW in true lumen. The inlet was in RCA-O near aortic root and RCA-dissection with extension to RCA-D. The IVUS also revealed lumen size was 4.0 to 5.0 mm. Then we deployed bare-metal stent sequentially from RCA-D to RCA-ostium. In the end, IVUS showed stent well apposed over the vessel from RCA-D to RCA-O. About the dissection of ascending aorta, we consulted CV surgeon and he suggested CT angiography after management of RCA dissection by PCI. After CTA, the surgeon suggested observation first and surgery would be done if hemodynamics change or poor healing in the following.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
withdrawn into the guiding catheter with traction of both wires andsuccessfully brought out and the small piece was also retrieved.
Case Summary. Dealing with heavy calcified lesion is challenging and needs proper technique to overcome. Sometimes we may need Mother and Child system in dealing the difficulty to deliver the stent. Catheter induced coronary dissection during PCI is a rare complication but life threatening especially in unprotected coronary artery which supply other disease vessel. Manipulation of child catheter may create dissection. Careful selection and manipulation of catheters and paying more attention to high-risk lesion are important to avoid such complication. Prompt treatment with conventional stenting for coronary dissection is essential and lifesaving. TCTAP C-130 Retrieval of Broken Diagnostic Coronary Catheter Using Angioplasty Balloon Saurabh Goel1 1 Cumballa Hill Hospital, India [CLINICAL INFORMATION] Patient initials or identifier number. SA Relevant clinical history and physical exam. 50 year old male patient, hypertensive since 3 years, non-diabetic, nonsmoker recent history of hospitalization 8 days back for acute chest pain and treatment as acute inferior myocardial infarction. He was thrombolysed with tenecteplase pulse 66/min bp 150/86 cvs - nad rs – clear. Relevant catheterization findings. Coronary angiography was done from right femoral access. The LAD showed 50% proximal lesion and LCxwas dominant and normal. The RCA was arising anamously from high midlineorigin and could not be cannulated despite using several standard catheters. Anattempt was made using al1 catheter as it was thought that it may reach theorigin. But during manipulation the distal tip of about 4cm broke from theshaft and migrated to upper thoracic aorta. [INTERVENTIONAL MANAGEMENT] Procedural step. Retreival of the catheter piece was attempted using available loop basket snare but it unsuccessful.Right angle loop snare was not available at that time in the cath lab. Punchbiopsy forcep was then used which gripped the shaft of the catheter piece andthe distal curved part of the amplatz catheter was removed. During themanipulation, a small 1.5 cm part of the shaft proximal to the point ofattachment of the forcep broke and migrated into a branch of the femoralartery. The left femoral artery was then punctured and through a cross over sheath. A multipurpose guiding was placed near the catheterpiece. Two coronary guide wires (0.0014) were passed through the lumen of thecatheter piece. On one of the wires a 2x10 mm angioplasty balloon was placed atthe centre of the catheter piece. It was inflated to 16 atm and the piece wassecured and
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Case Summary. A broken catheter piece in the arterial system is nightmare in the cath lab and requires out of the box thinking for retreival. In this case the broken piece was partly removedwith a punch biopsy forcep. Another smaller piece migrated to a smaller distalartery where thrombus formation was possible and surgical removal would havebeen very difficult. An innovative strategy of two coronary guide wires and angioplastyballoon inflated in the lumen of the piece was used to successfully remove thebroken catheter. TCTAP C-131 Iatrogenic Dissection of Right Coronary Artery Concomitant with Antegrade Aortic Dissection Chun-Yen Chiang,1 Po-Sen Huang,1 Chen-Chuan Cheng,1 Po-Ming Ku1 Chi-Mei Medical Center, Taiwan
1
[CLINICAL INFORMATION] Patient initials or identifier number. 10854785 Mrs. Li Relevant clinical history and physical exam. This 71 years old female with obese figure suffered from crescent chest tightness since yesterday. She has the medical history of hypertension and diabetes mellitus with poor control (HbA1C 9.0%). She reported the discomfort was dull pain, persisted for more than 10minutes and accompanied diaphoresis and dyspnea but no radiation. This angina was partially relieved by resting and nitroglycerin 1 tab sublinqual use. Physical exam revealed no heart murmur or rales over chest. Relevant test results prior to catheterization. No dynamic elevation of cardiac enzyme in 4 hours was noticed. Serial ECG showed atrial fibrillation with moderate ventricular response and no2015 obvious or significant ST-T change was noted. Reference
hs-Troponin<26.2 pg/mL
CK-Total29-168
CK-MBmass <3.4 ng/mL
U/L 2015/09/06 ER
hs-TroponinI[3.40 pg/mL]
CK-Total[44U/L]
CK-MBmass[0.7 ng/mL]
4 hours later
hs-TroponinI[4.20 pg/mL]
CK-Total[49U/L]
CK-MBmass[0.8 ng/mL]
S251
Relevant catheterization findings. Post-Cath Diagnosis: CAD (1-V-D) over RCA with iatrogenic spiral dissection extending to ascending aorta. Engaging catheter: RCA: JR4.0; LCA: JL3.5 Dominant: RCA LM: Normal LAD: Normal LCX: Normal RCA: Spiraldissection involved aortic root with contrast stasis and RCA-ostiun to RCA-D with TIMI II when engaged into RCA-ostium by guiding catheter of JR4(Boston). The 12-leadECG showed ST elevation and the patient felt chest pain with radiation to back. Meanwhile, BP 150/84mmHg, HR: 65 bpm and SPO2: 95%. [INTERVENTIONAL MANAGEMENT] Procedural step. Due to bradycardia and hypotension, we deposited temporary pacemaker and the condition became relatively stable. Later, we finished left coronary angiography, which showed no lesion. Under the guiding catheter of JR4.0, 6Fr(Bosten) via left radial approach, the first guidewire(GW) of Fielder(Asahi) cross RCA-lesion smoothly and then we put the IVUS into RCA-D and showed GW into false lumen from RCA-O to RCA-D. We decided to put another GW of Filder into RCA again. Finally, IVUS showed second GW in true lumen. The inlet was in RCA-O near aortic root and RCA-dissection with extension to RCA-D. The IVUS also revealed lumen size was 4.0 to 5.0 mm. Then we deployed bare-metal stent sequentially from RCA-D to RCA-ostium. In the end, IVUS showed stent well apposed over the vessel from RCA-D to RCA-O. About the dissection of ascending aorta, we consulted CV surgeon and he suggested CT angiography after management of RCA dissection by PCI. After CTA, the surgeon suggested observation first and surgery would be done if hemodynamics change or poor healing in the following.