Ostial RCA Intervention: Guiding Catheter Challenges and Use of a Buddy Wire to Perform Focused-Force Angioplasty on a Severely

Figure 2. Hockey stick guiding catheter sitting outside the right coronary ostium not allowing the Pilot 50™ wire to pass into the vessel.
Figure 3. LIMA guiding catheter allowing passage of 2 Pilot 50™ wires into distal right coronary artery.
Figure 4. Result post-final balloon (2.5 x 20 mm) inflation in the ostial right coronary artery.
Figure 1. Nonselective angiogram with a Williams (or 3DRC) right diagnostic catheter demonstrating a critical ostial right coronary lesion with an aorto-ostial calcium bar.
Figure 5. Deployment of a 3.5 x 24 mm Taxus® drug-eluting stent with 1–2 mm hangout into the aorta, demonstrating good coverage of the aorto-ostial junction.
Figure 6. Final result post-flaring of ostium with a noncompliant 3.75 mm balloon demonstrating a widely patent and flared ostium.
Author(s): 

Farrukh Hussain, MD, FRCPC, Tarek Kashour, MD, Mahadevan Rajaram, MD

Case Report. A 67-year-old female presented to our catheterization laboratory with a recent history of unstable angina for 3 weeks. Her cardiac markers were normal. Her past history was significant for diabetes, hyperlipidemia, hypertension and obesity. She subsequently underwent stress testing at another hospital, which was strongly positive. The paieint was therefore referred for angiography.
The left main coronary artery was unremarkable and the left anterior descending vessel had mild disease only. A small-caliber first obtuse marginal had a tight ostial lesion and the circumflex had mild-to-moderate disease. The culprit stenosis appeared to be a critical 95–99% stenosis at the ostium of the right coronary artery (RCA) with moderate disease distally at the proximal segment of the posterior descending branch, and mild stenosis in the mid RCA (Figure 1). There was only TIMI 2 flow down the RCA.
There was significant difficulty in intubating the RCA with both JR4 and Williams right (3DRC/No-Torque) diagnostic catheters. Therefore, adequate nonselective pictures were taken with the Williams right (3DRC/No-Torque) catheter, which came reasonably close to the ostium (Figure 1). An Amplatz left catheter was not tried due to the risk of injuring or dissecting such critical and calcified ostial disease. A multipurpose or Amplatz right catheter were thought to be the wrong geometry for engagement of this ostium. The cineangiographic images showed a thick bar of calcium at the aorto-ostial junction, preventing engagement of our catheters (Figure 1). After discussion with the patient and family regarding the risk of the procedure and the possibility of requiring single-vessel bypass surgery, we opted for percutaneous intervention.

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