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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 96-99

Crossing the calcium spur with “sliding over the balloon technique” in anomalous anterior origin of right coronary artery with two right-angle bends


Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission22-Jun-2021
Date of Decision16-Aug-2021
Date of Acceptance22-Sep-2021
Date of Web Publication03-Nov-2021

Correspondence Address:
Dr. Debasish Das
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_37_21

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  Abstract 


We present a simple novel technique of crossing the calcium spur at right-angle bend in coronary artery by deploying a noninflated balloon over the calcium spur where the tip of the passing stent frequently hits and create difficulty in negotiation of the stent forward. When we deploy a balloon over the calcium spur, the tip of the stent does not hit the edge of the calcium spur and the stent gently slides over the hydrophilic slippery balloon forward with ease. We describe a rare case of intervention in anomalous anterior origin of right coronary artery where we were not able to pass the stent across two 90° bends which were harboring calcium spur. In spite of we adopted buddy wire and triple wire technique to make the bend straight, we were not able to move the stent forward, each time it was hitting at the edge of the calcium spur. We put a 2 mm × 10 mm noninflated semicompliant balloon each time while crossing the right-angle bend with calcium spur which covered the calcium spur and over the balloon we were easily able to slide the stent forward, deployed the stent across the lesion, and achieved distal TIMI III flow. We describe this simple novel technique of “sliding the stent over the balloon technique” to cross the calcium spur remaining at 90°-angle bend causing difficulty in forward negotiation of the stent.

Keywords: Balloon technique, calcium spur, sliding over


How to cite this article:
Das D, Acharya D, Singh J, Pramanik S, Das T. Crossing the calcium spur with “sliding over the balloon technique” in anomalous anterior origin of right coronary artery with two right-angle bends. Res Cardiovasc Med 2021;10:96-9

How to cite this URL:
Das D, Acharya D, Singh J, Pramanik S, Das T. Crossing the calcium spur with “sliding over the balloon technique” in anomalous anterior origin of right coronary artery with two right-angle bends. Res Cardiovasc Med [serial online] 2021 [cited 2021 Dec 3];10:96-9. Available from: https://www.rcvmonline.com/text.asp?2021/10/3/96/329845




  Introduction Top


We describe a novel technique of crossing the calcium spur across the bend by putting a semicompliant balloon over it so that the balloon will cover the calcium spur and the stent will slide over it, move forward with ease and edge of the calcium spur will not be an obstruction in forward movement of the stent. We encountered difficulty in passing the stent across the right angle which was harboring the calcium spur and each time we were trying to pass the stent forward the tip of the stent was hitting at the edge of the calcium spur and the stent was not moving forward. To overcome this difficulty, we deployed a semicompliant balloon over the calcium spur and slided the stent over the semicompliant balloon forward and deployed. This simple technique allows the operator to cross the stent across the right-angle bend with calcium spur in order not to leave the lesion after simple plain old balloon inflation.


  Case Report Top


A 52-year-old male presented with acute onset retrosternal chest discomfort for the past 8 h with shortness of breath and diaphoresis with blood pressure of 106/70 mmHg and pulse rate of 58 beats/min, electrocardiogram revealed acute inferior wall ST-elevated myocardial infraction and echocardiography revealed regional wall motion abnormality in basal interventricular septum and inferior posterior wall. He was diabetic, hypertensive, and smoker. Right coronary injection revealed anomalous anterior origin of right coronary artery (RCA) with long segment diffuse disease from proximal segment with two 90° bends harboring subtotal occlusion [Figure 1]. We crossed the lesion with 0.014” Fielder FC guide wire and dilated the lesion with 1.5 mm × 8 mm and 2 mm × 10 mm semicompliant balloon at 16 and 14 atm pressure, respectively, followed by dilation with 2 mm × 8 mm and 2.5 mm × 8 mm noncompliant (NC) balloon at 22 and 20 atm pressure, respectively, to modify the calcium. We were not able to advance the stent further which was getting stuck each time at the first right-angle bend. We first adopted a buddy wire and then a triple wire technique [Figure 2] to straighten the right-angle bend so that the stent can pass forward; in spite of the buddy wire making the right-angle straight, we were not able to push the stent forward as each time the calcium spur at the right angle was obstructing the stent to move forward. To overcome this difficulty, we deployed a 2 mm × 10 mm noninflated semicompliant balloon over the calcium spur [Figure 3] so that it would cover the calcium spur and calcium spur will not make obstruction in passage of the tip of the stent. We gently slided a 3 mm × 24 mm drug-eluting stent (DES) distally over the balloon [Figure 4], taken out the balloon, placed the stent across the lesion, and deployed at 16 atm pressure [Figure 5]. Post deployment, we attempted stenting the lesion distally. We faced the same problem while crossing the stent at the second bend, each time we were trying to move the stent forward the calcium spur was hindering the passage of the tip of the stent. We adopted the same technique again, deployed a 2 mm × 10 mm noninflated semicompliant balloon across the site of obstruction and gently slided a 2.75 mm × 20 mm DES across the lesion, taken the balloon back, and deployed the stent at 14 atm pressure. Post deployment RCA revealed TIMI III flow [Figure 6] and patient's hemodynamics were stable. We could cross the calcium spur at the bend with this “Sliding over the Balloon” technique [Figure 7] and successfully deployed the stent.
Figure 1: First and second 90° bend with calcium spur with anterior origin of right coronary artery

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Figure 2: Triple wire support could not make the first bend straight to negotiate stent

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Figure 3: Putting a balloon across the first bend

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Figure 4: Sliding the stent over the balloon over the first wire

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Figure 5: Good angiographic result in proximal segment

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Figure 6: Same maneuver repeated in distal bend and final good angiographic result

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Figure 7: Procedural steps for “Sliding Over the Balloon Technique”

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  Discussion Top


Kaluski et al. described anterior origin of RCA in a case of acute myocardial infarction, in which they were unable to selectively engage the RCA.[1] Our case had anomalous anterior origin of RCA from right sinus for which it was difficult to engage with the conventional Judkins right catheter. We first airmailed the Fielder FC wire into the proximal segment of RCA, and then, we were able to engage the guide catheter. Guide catheter became stable after we adopted the buddy wire technique only. Villalonga,[2] Banchi,[3] and Hackensellner[4] described RCA originates from the posterior third, middle third, and anterior third of the right sinus in 40%, 59%, and 1% cases, respectively. Since 99% of RCA originates from the posterior two-third of the right sinus, ectopic RCA is defined as RCA originating outside this zone. The most common location of ectopic RCA is the anterior third of the right sinus also called anteriorly displaced RCA. To selectively engage this ectopic RCA in this location, the optimal catheter is Amplatz left 1 catheter.[5] In 30 RAO projection, the catheter should be pointing anterior or to the right. Multipurpose, extra back up and Voda Catheter can be used to engage this anomalous RCA. Calcium spur inside the coronary artery hinders coronary hardwire advancement. We modified the calcium with NC balloon dilatation which was also not able to break the calcium spur, and we were not able to push the stent further. We are describing this simple novel technique of crossing the calcium spur which obstructs the tip of the passing stent to move forward; to overcome this difficulty, we put a noninflated semicompliant balloon covering the calcium spur, so that over the slippery surface of the balloon, the stent will move forward and calcium spur cannot cause obstruction. This “sliding over the balloon technique” overcomes the obstruction caused by the calcium spur. Quite often NC balloon dilatation also does not become successful in breaking the calcium spur significantly to ease the forward movement of the stent. To break a single large calcium spur, rotablation is not usually indicated nor the intravascular lithotripsy. Inability to move the stent forward ends the procedure with only simple balloon dilatation which carries the risk of immediate stent thrombosis and future restenosis. Due to difficulty in passage of the stent across the calcium spur in the first bend, we stented the coronary artery in reverse order, stented the proximal segment first, and DES covered the calcium spur for which we were able to take the second stent through the first stent to stent the distal segment; although in routine practice, coronary artery is sequentially stented from distal to proximal segment. Before adopting this “sliding over the balloon” technique, we initially thought the bend is causing difficulty in negotiation of the stent. Hence, we adopted buddy wire technique to straighten the bend which stabilized the RCA guide, but we could not move the stent forward. To further straighten the bend, we adopted the triple wire technique in which we put three guide wires in coronary artery to straighten the coronary bend which also could not help in passing the stent forward for which we thought it is the calcium spur which was causing the obstruction in the passage of the coronary stent and was also well evident during coronary injection. After putting a semicompliant balloon covering the calcium spur, we were able to easily slide the stent forward over the balloon to place it across the lesion in coronary bend and subsequently deployed them. Gedela et al.[6] described a triple guide wire technique for treating stent under expansion, where the presence of multiple guide wires exerted uniform force across the lesion. We used the triple guide wire technique to straighten the bend in coronary artery to allow smooth passage of the stent, but we could not move the stent forward due to the presence of calcium spur. One disadvantage of putting multiple guide wires inside the coronary artery is that it increases the risk of periprocedural stent thrombosis; we adequately heparinized the patient with 10,000 IU of unfractionated heparin and maintained the ACT between 250 and 300 ms. Calcium and thrombus are two known potential threats during coronary intervention, we overcame the obstruction imposed by the calcium spur with this simple and novel “sliding the stent over the balloon” technique and successfully performed the angioplasty.


  Conclusion Top


We have described a simple and novel technique of crossing the calcium spur which hinders the passage of the stent across a right-angle bend with “sliding over the balloon” technique. Young interventionists can use this simple technique while facing difficulty in stent negotiation across bends and calcium spur. Small and simple techniques may often suffice in successful coronary angioplasty.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaluski E, Solanki P, Sanchez-Ross M, Saric M, Randhawa P, Klapholz M, et al. Anteriorly displaced right coronary artery in acute myocardial infarction: What should every cardiologist know. Cardiovasc Revasc Med 2011;12:59-64.  Back to cited text no. 1
    
2.
Villalonga JR. Anatomic variation of coronary arteries:I. The most frequent variations:Eur J Anat 2003;7:29-41.  Back to cited text no. 2
    
3.
Banchi A. Morphologia delle arteriae coronariae cordis. Arch Ital Anat Ebriol 1904;3:87-164.  Back to cited text no. 3
    
4.
Hackensellner HA. Koronaranomalien unter 1000 auslesefrei untersuchten Herzen. Anat Anz 1954;101:123-30.  Back to cited text no. 4
    
5.
Yip H, Chen MC, Wu CJ, Yeh KH, Fu M, Hang CL, et al. Primary angioplasty in acute inferior myocardial infarction with anomalous-origin right coronary arteries as infarct-related arteries: Focus on anatomic and clinical features, outcomes, selection of guiding catheters and management. J Invasive Cardiol 2001;13:290-7.  Back to cited text no. 5
    
6.
Gedela M, Li S, Desai C, Stys T, Stys A. Triple-guidewire technique for treating stent underexpansion in severely calcified coronary artery lesions. Tex Heart Inst J 2020;47:155-9.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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