Challenging Aorto-Coronary Occlusion: Which Solution?

J INVASIVE CARDIOL 2019;31(1):E1.

Key words: aorto-coronary occlusion, acute coronary syndrome, cardiac imaging, microcatheter

An 86-year-old woman was rescued by the emergency team for inferior ST-segment elevation myocardial infarction complicated by cardiogenic shock. Echocardiogram showed severe dilation of the right ventricle with compromise of its ejection function. Coronary angiography (right femoral artery access) showed heavily calcified plaque at the origin of the right coronary artery (RCA) with total ostial occlusion of the vessel (Figure 1) and TIMI 0 flow; there was no evidence of significant collateral circulation from the left coronary artery. After placement of a 6 Fr hockey-stick guiding catheter (HS2) in the right coronary sinus without selective engagement of the RCA ostium, we advanced an intermediate coronary guidewire over the occlusion (Figure 2A). There was no way to advance the 1.25 mm Tazuna balloon (Terumo) over the RCA ostium (Figure 2B). We opted to penetrate the plaque with a FineCross MG microcatheter (Terumo) (Figure 2C) to obtain enough space to perform coronary angioplasty. We then performed multiple inflations with semicompliant (from 1.25 to 2.0 mm) and non-compliant (from 2.5 to 4.0 mm) catheter balloons and implantation of a 4.5 x 18 mm everolimus-eluting stent (Figure 2D) in the RCA ostium. Good angiographic result showed evidence of developed RCA with great posterior descending artery (PDA) that extended beyond the heart apex (Video 1). The hemodynamic setting stabilized and the patient was transferred to the intensive care unit to continue monitoring.

Aorto-coronary occlusion is a particularly difficult lesion to treat, especially in an emergent setting. Chronic total occlusion techniques and devices are useful in these situations. In this case, it was impossible to perform a retrograde approach or plaque debulking as described in the literature; to our knowledge, this is the first description of the use of a microcatheter not to support the guidewire, but to open an aorto-coronary calcific occlusion with anterograde approach in an emergent situation.

From the Unità Operativa Complessa di Cardiologia, Ospedale San Francesco, Nuoro, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted July 24, 2018. 

Address for correspondence: Giovanni Lorenzoni, MD, Ospedale San Francesco, Unità Operativa Complessa di Cardiologia, via Mannironi 1, Nuoro, Italy. Email: giovannilorenzoni@alice.it