3372228

A 89 Male       History of CAD s/p PCI with stenting to LAD, HTN, ESRDCAD risks: Hypertension, Smoke, Family history, Old age, MaleClinical presentation: Chest pain with cold sweating after regular hemodialysisVital sign at ER: BT  36.4 ℃ , BP 127/60 mmHg, HR 70 b.p.m.,  SaO2 100% in room air.Physical examination: regular heart beat with mild systolic heart murmurECG: Lead II, III,  aVF STE with V4R, V5R, V6R STE

LM: A discrete 50-60% eccentric stenosis lesion at M/3Ramus: Luminal irregularity and diffuse atherosclerosiLAD: Luminal irregularity and diffuse atherosclerosis- P/3: s/p stent, with 50% type III in-stent restenosis (ISR)LCX: Luminal irregularity and diffuse atherosclerosiRCA: Luminal irregularity, dominant vessel, diffuse calcification- Ostium: Diffuse eccentric 90-95% stenosis-Total occlusion at M/3 with microchannel to D/3Syntax score: 39

-The RCA ostium was engaged by SAL 1.0 guiding catheter.-A SION Black wire in a FineCross microcatheter was used to wire through the critical stenotic lesion at m-RCA and advanced to PDA.-The microcatheter was removed via assistance of an Extension wire.-The  os to d-RCA was pre-dilated by 2.0x20mm balloon.IVUS: There was a dissected flap at os-RCA and the cracked calcification at m-RCA lesion was noted. The MLA at os-RCA was 4.99 mm2 with diameter 1.78-3.55 mm.-The lesion from os to d-RCA was dilated by 3.0x15mm NC balloon and 4.0x15mm NC balloon.-Dissection flap with lumen collapse was noted.-Under balloon assisted, a GuideLiner (6 Fr.) catheter was delivered to p-RCA to strengthen the back-up force.-The stenotic lesion at os to d-RCA was dilated by 4.0x15mm NC balloon.-The GuideLiner advanced to m-RCA using balloon assisted tracking technique by 2.0x20mm balloon.-A 4.0x43mm DES was deployed to m to d-RCA with the GuideLiner catheter assisted.-A 4.0x32mm DES was deployed to os to m-RCA with distal stent overlapping and proximal stent minimal protruding out of the RCA ostium.-Post-dilation to the two stents was performed by 4.5x12mm NC balloon.IVUS: Adequate apposition of the stent struts over os to d-RCA. The cross sectional area over RCA ostium was 16.38mm2 with diameter 3.30-5.45mm. The minimal stent area was 11.63mm2 with diameter 2.85-5.08mm at m-RCA.-The final angiography showed <10% residual stenosis over m-RCA stent with TIMI 3 distal runoff.

We present a CHIP case presenting with STEMI, inferior wall myocardial infarction, and culprit lesion at RCA. Mechanical support and temporary pacemaker always need to keep in mind to maintain the patient’s hemodynamic status when encountering such as CHIP case. A good choice of guiding would make the whole procedure more safe and smoothly. Although it was a STEMI case, the intra-procedural image still played an important role when facing to the long diffuse calcified lesion. Dedicated calcification modification was essential and associated with stent expansion rate. It was practicable to deliver the Guideliner catheter into the dissection lesion under balloon assistance without further injury.