Journal of Invasive Cardiology

Case Description. A 69-year-old female with hypertension and hyperlipidemia presented with a 2-month history of worsening exertional angina. Nuclear perfusion imaging indicated ischemia in the inferior and inferoposterior walls, with preserved left ventricular function. Coronary angiography was notable for severely calcified vessels and a right dominant circulation. The left anterior descending and left circumflex arteries were free of critical stenosis, but the right coronary artery was tortuous in its proximal segment, with a 99% mid-vessel lesion that appeared as a calcified, obstructive filling defect on orthogonal imaging (Figure 1).
Coronary intervention proceeded utilizing a 7 Fr Left Amplatz 1.0 guiding catheter. Due to proximal curvature, the wire was repeatedly deflected away from the residual lumen despite multiple attempts with different conventional wires and balloon catheter backup. This included attempts with BMW (Guidant Corp., Indianapolis, Indiana), Asahi Soft (Abbott Laboratories, Abbott Park, Illinois), and ChoICE™ PT2 (Boston Scientific, Natick, Massachusetts) wires. It was determined that poor support and an inability to precisely direct the wire toward the residual lumen were precluding success. A final attempt was thus made using the Venture™ steerable wire control catheter (Velocimed, Minneapolis, Minnesota). The catheter was positioned at the proximal bend and directed 90 degrees inferiorly into the mid-vessel. This provided directability and pushability to allow a soft, hydrophilic wire to pass alongside the stenosis with minimal resistance. Figure 2 shows the coronary guidewire across the stenosis, with the Venture catheter seated in the proximal vessel. The wire passed freely to the distal vasculature, and the Venture catheter was removed. After exchanging for a rotational atherectomy extra support wire, multiple passes were made with a 1.5 mm burr. Serial balloon dilatations and 3.5 mm drug-eluting stent placement to the proximal and mid-vessel produced the final result (Figure 3). The patient was discharged without events the following day.