Case 112: PCI Manual - Aorto-ostial stent challenges

A patient who had undergone stenting of the right coronary artery from the distal segment to the ostium presented with focal in-stent restenosis of the mid RCA. Engagement of the RCA was challenging, likely due to overhang of the previously placed stents into the aorta, but was eventually achieved using a JR4 guide catheter and the “hit and run” technique (guidewire placed at the tip of the guide catheter and advanced into the target vessel as soon as the guide becomes aligned with the coronary ostium). A knuckled wire was then advanced into the RCA to minimize the risk of sub-stent wiring. Equipment delivery to the RCA was challenging, however, requiring balloon angioplasty of the proximal RCA. After successful stenting of the mid RCA lesion IVUS revealed stent deformation of the previous ostial RCA stent that required implantation of an additional DES.