Case 187: Manual of PCI - STEMI at 3 am

An elderly patient with prior CABG presented with inferior STEMI. Diagnostic coronary angiography done via right common femoral access was challenging due to aortic tortuosity but eventually suggested that the culprit was a lesion in the native right posterolateral. We could not engage the RCA with a guide catheter despite using a 65 cm long femoral sheath. Eventually we engaged the RCA with a diagnostic JR4 guide catheter, inserted a 300 cm long Grand Slam wire and inserted a 7 French AL1 guide over the Grand Slam wire. The right posterolateral became larger after balloon angioplasty but DES placement resulted in TIMI 1 flow in its first branch. The patient had resolution of the chest pain despite a significant residual stenosis in the right posterolateral.