Lots of interesting abstracts and cases were submitted for TCTAP 2022. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!
TCTAP C-094
Catastrophic Concertina With Unavoidable Stenting
By Panduranga Prashanth
Presenter
Prashanth Panduranga
Authors
Panduranga Prashanth1
Affiliation
National Heart Center, Oman1,
View Study Report
TCTAP C-094
CORONARY - Complications
Catastrophic Concertina With Unavoidable Stenting
Panduranga Prashanth1
National Heart Center, Oman1,
Clinical Information
Patient initials or Identifier Number
MA
Relevant Clinical History and Physical Exam
A 60-year-old male, diabetic, hypertensive, smoker, old CVA recovered, eGFR 51, no past MI presented with exertional angina and dyspnea class II-III.
8 years ago CAG- Mid LAD 90% lesion, RCA mid 70% lesion, LCX normal, refused PCI.
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8 years ago CAG- Mid LAD 90% lesion, RCA mid 70% lesion, LCX normal, refused PCI.
video2.avi video3.avi video5.aviRelevant Test Results Prior to Catheterization
ECG ECG- LVH, SR, Echo EF 35% with severe hypokinesia of IVS, apex and anterior wall. Nuclear scan nonviable LAD, rest viable.
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video7.avi video8.avi video12.aviRelevant Catheterization Findings
CAG - RCA tortuous vessel, mild proximal disease, 95% mid tight lesion, LAD 90% mid lesion, LCX minor plaques. Proceeded for RCA PCI.
Rt. femoral approach, 6F arterial sheath, Very tortuous right iliac, exchanged to long sheath, JR4 difficult cannulating shepherd crook RCA, with Run-through floppy wire could take nonselective injection. Guide not sitting well, wire not negotiating, changed to AL1.
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Rt. femoral approach, 6F arterial sheath, Very tortuous right iliac, exchanged to long sheath, JR4 difficult cannulating shepherd crook RCA, with Run-through floppy wire could take nonselective injection. Guide not sitting well, wire not negotiating, changed to AL1.
video13.avi video14.avi video16.aviInterventional Management
Procedural Step
AL1 - Run-through floppy. It was very difficult to take a 2 x 15 mm Balloon towards mid segment. Needed another BMW wire to push balloon towards mid segment. Noticed severe constriction proximally suggestive of pseudo-lesion with slow flow. Predilated mid segment at 14 atms.
After removal of balloon, there was acute closure proximally with ST elevation on monitor with hypotension 90/60 mmHg. Second wire removed, but no relief, hence was decided to stent, to establish flow and also to facilitate stenting of mid segment as it was thought this concertina effect will repeat if again another wire/balloon/stent inserted. Once stent balloon inserted which partially relieved the concertina,there was flow established. Also the position of stent balloon in true lumen ruled out any dissection.
3.5 x 18 mm DES @ 14 atms deployed proximal RCA with compelte flow established and relief of ST elevation. 2.5 x 15 mm balloon was unable to pass through mid segment. Second wire again inserted. Balloon positioned in the mid segment and inflated @ 14 atms, balloon and buddy wire removed. 3.5 x 23 mm DES @ 16 atms deployed in mid RCA overlapping with proximal stent. Post dilated both stents with 4 x 8 mm NC @ 16, 16 atms.
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After removal of balloon, there was acute closure proximally with ST elevation on monitor with hypotension 90/60 mmHg. Second wire removed, but no relief, hence was decided to stent, to establish flow and also to facilitate stenting of mid segment as it was thought this concertina effect will repeat if again another wire/balloon/stent inserted. Once stent balloon inserted which partially relieved the concertina,there was flow established. Also the position of stent balloon in true lumen ruled out any dissection.
3.5 x 18 mm DES @ 14 atms deployed proximal RCA with compelte flow established and relief of ST elevation. 2.5 x 15 mm balloon was unable to pass through mid segment. Second wire again inserted. Balloon positioned in the mid segment and inflated @ 14 atms, balloon and buddy wire removed. 3.5 x 23 mm DES @ 16 atms deployed in mid RCA overlapping with proximal stent. Post dilated both stents with 4 x 8 mm NC @ 16, 16 atms.
video19.avi video20.aviCase Summary
Accordion or Concertina phenomenon is not uncommon produced by straightening and shortening of a tortuous long artery i.e. "web-like" eccentric constrictions induced by stiff guidewire. These protruding folds induce several consecutive tight stenosis.These pseudo-lesions can be inappropriately identified as coronary spasm, dissection or thrombus development.However, in this case there was severe concertina effect with critical eccentric constriction proximally with no flow, hemodynamic instability and removing wire and checking for concertina effect was high risk of losing patient which necessitated stenting.