56 yearsold MalePremorbid

1. IHD – PCI to LAD 2015
2. HPT
3. DM
4. Dyslipidemia

Presentedwith Angina on exertion past 1/12UnderwentMSCT cardiac in India during trip there 1/12 agoFindingsshowed Moderate severe OM 1 and proximal to mid RCA 
On examination, Well, not tachypnoeicBP : 130 /80 mm HgHR : 100 bpmSpo2 : 98% on room airLungs : ClearCVS : DRNMNo pedal edema 

Coronary angiogram :
Left Main Stem : normalLAD : Patent stent , mild diseaseLCX : mild diseaseRCA : Anomalous origin, tight stenosis at mid segment

QFR RCA was 0.76 ( Significant lesion )Right radial approach . JR 3.5 used to try engage RCA Wired downdistally for better support and engagementPredilatedwith SC 2.5 x 15mm balloon. Had difficulty to advance the balloon further due to tortuosity and poorsupport. Decided to use guide extension catheter - GUIDE PLUS II for extrasupport and successfully predilated further. Stented with DES 2.75 x 26mm at nominalPlan forpostdilation with NC 2.75 x 15mm balloon, but unable to advanceDespite Guideextension catheter deeper engangement for support, unable to advance to stentarea and postdilate with balloon. Attempte to use a smaller 2.5 x 10mm butstill cannot advance the balloon. Used buddy wire technique but still unable toadvance balloon to postdilate. At this point, we decided to reflect and checkwhat actually happened. We realized the proximal stent strut were deformed ,possible by the guide extension catheter inadvertently during manipulation. Wewere able to appreciate this by using STENT BOOST with the balloon almost nearto the stent.  We tried touse a smaller SC 1.5 x 10mm and able to advance successfully after fewattempts. We then slowly predilated further with SC 2.0 x 10mm and NC 2.5 x 15mm.Finally used NC 2.75 x 15mm at high pressure. We were able to achieve goodangiographic results with TIMI III final flow distally. In addition , QFR postprocedure was 0.91. Patient was discharged well 2 days later. 

1. Anomalous RCA angioplastyrequires good guide support for co-axial engagement and to advance devices2. The use of guide catheter extension is increasingly used insuch similar cases. 3. Other techniques to ensure good outcome in anomalous Rightcoronary artery angioplasty include bigger Fr guide usage, good lesionpreparation, anchor or distal balloon technique, buddy wire stiffer wire usageor use shorter and compliant balloons. Stents which are shorter with compliantballoons will be beneficial4. In our case , the guide catheter extension itself damaged the newlydeployed stent despite careful manipulation