Doctor & Patient Education Cardiac Specialist Centre
Intervention
11. Be Careful with that Guide
  • Primary PCI for myocardial infarction is usually a relatively easy procedure
  • The plaque is usually very soft making passage of wire easy
  • Sometimes the pre-existing plaque may be already calcified
  • This with the presence of plaque upstream may make wire crossing a bit challenging
  • If the plaque is hardened, a good supporting guide is useful
  • Amplatz shaped guides provide good support
  • However, due to its shape, while on one hand provides good support, on the other makes it easier to create dissection at the ostium
  • The following patient presented with acute inferior ST-Elevation Myocardial Infarction
  • The attending doctor started with an Ikari Left 3.5 guide from the radial artery

 

Baseline angiogram

  • This baseline angiogram shows a complete occlusion at mid RCA
  • The operator started with a 6F IL 3.5 guide from the right radial

1 inf stemi

 

  • After trying for some time with a soft wire, he was unable to cross the lesion
  • He decided to change to stiffer wire
  • However, he was still not able to cross the lesion.
  • Thinking that he needed a more supportive guide, he decided to change to an AL 1
2 cant cross

 

  • Unfortunately, he caused dissection of the RCA ostium
3 change guide

 

  • Finding that he could not rewire the RCA with the AL1 guide, he changed to JR4 guide
  • In his panic, he wired into the subintimal space rather than the true lumen
4 diff wire

 

  • Thinking that he has wired the true lumen, he decided to stent the RCA ostium
  • In his haste, he has not realised that the wire is actually sitting in the false lumen
5 is this correct

 

  • After deployment of the stent, the RCA is now completely occluded
  • He decided that since patient is not complaining of chest pain, he would abandon the procedure
6 subint stnt

 

Discussion
  • Some acute coronary syndrome occur on the background of pre-existing subtotal occlusion
  • Wiring these lesions in the presence of fresh thrombus may sometimes be challenging
  • I find that the use of a tapered tip wire such as XT-R is very useful
  • The chances of finding a track is higher than normal work horse 'soft' wire
  • Sometimes the use of good supporting catheter is necessary
  • In this case, extreme care should have been taken when using the Amplatz type guide
  • The operator should also be careful when the wire is sitting
  • Unfortunately the wire was in the sub-intimal space when the stent is deployed
  • Long term wise, if the myocardium is not damaged, there may a chance of re-opening this lesion via the retrograde path
Consultation
Know Your Cardiologists

I feel breathless when walking.

I feel a tightness over my chest.

Do I need to take my medicine for my blood pressure?

Do I need to take my medicine for my cholesterol?

Do I really need stents for my artery?

Do I really need to have a bypass operation?

When should I go for health screening?

I have heart problem, can I take Viagra?

I have heart problem, should I exercise?

Heart Disease
Learn about your heart Conditions

You may need an ultra sound scan of your heart to assess its function.

You may need a treadmill stress test.

You may need closer monitoring.

You may need a more thorough risk assessment and life style change.

You may only need to take your medicine.

You may get away with just stenting.

This generally should start at 40 years old.

Yes, but there are certain strict conditions to fulfill.

Yes, but you will need to find out the appropriate intensity.