Case 108: PCI Manual - Murphy's law #2

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A patient presented with angina but had a negative stress test. Coronary CTA demonstrated a CT-FFR of 0.85 in the LAD and diagonal. Because of persistent symptoms she underwent coronary angiography that demonstrated a severe long mid LAD lesion with iFR of 0.83 after the takeoff of a large diagonal branch. Engaging the left main was challenging, but was eventually successful with an Ikari Left 3.5 guide catheter. The distal portion of the lesion was successfully stented with a 2.25x12 mm DES. Despite aggressive lesion predilation and use of a guide catheter extension, delivery of a 2.5x26 mm DES failed, as did an attempt to deliver a MicroCross 0.014 microcatheter. Using the side branch anchoring technique with a balloon in the diagonal branch we eventually succeeded in delivering the MicroCross 0.014 microcatheter to the distal LAD and exchanging the workhorse guidewire for a 300 cm long Wiggle guidewire. The patient had mid LAD dissection with chest pain and decrease in antegrade flow. Repeat attempt to deliver a DES resulted in stent loss. We failed to retrieve the stent using the small balloon technique. The stent was deployed in the proximal LAD and dilated with a 2.75 mm balloon. Eventually a DES was delivered and deployed in the mid LAD with a nice final result.