Double Balloon Angioplasty for Unstentable Large-Caliber Right Coronary Stenosis

Despite newer lower-profile stent technologies, placing coronary stents may still remain challenging when vessels are extremely tortuous. We describe a case of a very large-caliber right coronary artery (RCA) with a “shepherd’s crook” configuration, which could not be stented, and for which double balloon angioplasty was successfully performed.
Case Report. A 69-year-old Caucasian male was hospitalized for an acute coronary syndrome. Diagnostic heart catheterization revealed a 90% eccentric stenosis past the genu of the right coronary artery. The vessel was large, about 7 mm in caliber, and somewhat patulous, with a prominent “shepherd’s crook” configuration (a dramatic upturn with a near-180º switchback turn) (Figure 1).

We employed an 8 Fr system to improve backup support, and attempted to use various guide catheters for optimization including an Amplatz left 3 (Cordis Corp., Miami Lakes, Florida) and Voda right 2 (Boston Scientific Corp., Natick, Massachusetts), but found the best support with an Amplatz left 2 curve (Cordis). We were able to predilate the lesion with a 4.0 x12 mm Sprinter balloon catheter (Medtronic, Inc., Minneapolis, Minnesota) inflated to 12 atm for 30 seconds over a Balance Middle Weight Universal (BMW) 0.014 inch guidewire (Guidant Corp., Santa Clara, California), with luminal improvement. We attempted to place a Herculink 6.0 x 15 mm stent (Guidant) at the site of the stenosis, however, it could not navigate the proximal tortuous bend. The wire was exchanged for an Iron Man 0.014 inch guidewire (Guidant) for better support, but the stent still would not go around the first bend. A 5.0 x 22 mm NC Ranger balloon catheter (Boston Scientific Scimed, Maple Grove, Minnesota) was tried unsuccessfully, as was a 7.0 x 20 mm peripheral balloon, also unsuccessfully. To help facilitate the distalexcursion of these balloons, a BMW universal 0.014 inch guidewire was employed as a “buddy wire”.
We then placed the original 4.0 x 12 mm Sprinter balloon at the stenosis and, adjacent to it, a second Sprinter (4.0 x 15 mm), and inflated them simultaneously, side by side at 8 atm each, however, the result was suboptimal. Thus, we tried a Grand Slam guidewire (Abbott Vascular Devices, Redwood City, California) with a 6.0 Symmetry balloon catheter (Boston Scientific) along with the buddy wire, unsuccessfully, and then the NC Ranger balloon catheter again, also unsuccessfully.

Next, we tried to place an Absolute stent (Guidant) at the lesion, attempting to anchor the mid-vessel with the NC Ranger balloon catheter to better seat the guide as the stent came around the shepherd’s crook. As this did not help, we then tried placing 2 NC Rangers side by side, but these balloon catheters were unable to reach the lesion.
Ultimately, we had to resort to placing the 2 Sprinter balloons again, as before, and dilated each simultaneously to 20 atm for 50 seconds. (Figure 2). We were finally able to achieve a satisfactory result (Figure 3). The patient has remained symptom-free 1.5 years later.

Discussion. Coronary balloon and stent technologies have significantly advanced, but there are still situations where coronary anatomy challenges even our newest tools. Our case exemplifies a very large-caliber, tortuous right coronary anatomy precluding the placement of a large-caliber stent, and requiring instead the placement of 2 very low-profile balloon catheters that were inflated simultaneously side by side to achieve adequate lesion dilatation.