Case Presentation. We present the case of 65-year-old male of Asian descent with diabetes mellitus. He had a history of myocardial infarction in 2004. At that time, he underwent percutaneous coronary intervention to his left anterior descending artery (LAD) and a technically difficult intervention to his right coronary artery (RCA). Failure to track the drug-eluting stent (DES) in the RCA occurred due to tortuosity of the vessel (even after 8 Fr and “buddy-wire” support). The procedure was eventually completed with deployment of a bare-metal stent (BMS).
The patient remained on dual antiplatelet therapy for 1 year. Repeat angiography 1 year later revealed patent LAD stents but subtotal occlusion of the RCA with in-stent stenosis of the BMS. Repeat intervention was not attempted due to the technically difficult initial procedure, thus the patient was managed medically. He was continued on aspirin 75 mg, atorvastatin 40 mg and bisoprolol 5 mg. The patient re-presented in 2007 with recurrent disabling atrial fibrillation thought to be of ischemic origin. Repeat angiography revealed patent LAD stents and the RCA showed diffuse significant stenosis in the proximal and mid vessel within the BMS with occlusive disease more distally up to the bifurcation of the patent ductus arteriosus and posterolateral branch (Figure 1). Left coronary injection revealed that the RCA supplied a large and significant territory. Bisoprolol was changed to sotalol 80 mg, without clinical improvement.

PCI of the RCA was attempted. Clopidogrel 75 mg was given for 10 days prior to the procedure. Right femoral 6 Fr access was gained, and 6000 units of heparin were administered. A Heartrail AL1 100 cm guiding catheter (Terumo Medical, Somerset, New Jersey) was used to cannulate the RCA, and a Whisper guidewire (Abbott Vascular, Santa Clara, California) used to cross the chronic total occlusion (CTO). The lesions were predilated with a 1.25 x 15 mm and a 2.5 x 20 mm Ryujin balloon (Terumo) (Figure 2). A Cypher^™ Select Plus 2.75 x 33 mm stent (Cordis Corp., Miami Lakes, Florida) would not track beyond the proximal part of the RCA despite the use of a buddy wire. A 5 Fr Heartrail guiding catheter (Terumo) was then inserted through the AL1 guiding catheter into the RCA for extra support, but did not reach far enough. An inflated 2.5 x 20 mm Ryujin Plus balloon was used as an anchor within the mid vessel (Figure 3), which allowed the 5 Fr catheter to deep seat further into the mid vessel. Two Cypher Select Plus stents (2.75 x 23 mm and 3 x 33 mm) tracked with ease this time and were deployed in the distal vessel (Figure 4).
The 5 Fr catheter was removed and the proximal vessel was stented with 3.5 x 33 mm Cypher Select Plus and a 4 x 18 mm Xience stent (Abbott Vascular) (Figure 5). All stents were then postdilated with a 3.5 x 20 mm Firestar balloon (Cordis), producing an excellent final result (Figure 6). The total duration of the procedure was 100 minutes; a total of 260 mls of contrast was used. The fluoroscopic time was 24 minutes with a DAP dose of 9282 Gy cm2. The 5 Fr-in-6 Fr “mother-and-child” guiding catheter system allows ultra-deep seating to increase backup support and assist stent delivery. This was paramount in this case due to stent tracking failure in the past. The 5 Fr Terumo Heartrail catheter can be used in any 6 Fr guiding catheter, which has a minimum lumen of 0.071 inches and a PTFE inner coating.