PMC5215179_01
Angiogram and intravascular ultrasound (IVUS) image (Opticross; Boston scientific, Japan) at the right ventricular (RV) branch bifurcation after guidewire crossing and suction. IVUS image revealed that culprit lesion included attenuated plaque, and the RV branch was running through the plaque (white arrow). A small branch was also seen at the opposite side of RV branch by the angiogram and IVUS
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Fig1
IVUS showed attenuated plaque at the lesion site involving the RV branch orifice (Fig. 1).
Angiogram after stenting showed that the right ventricular (RV) branch remained completely occluded. Intravascular ultrasound image from the right coronary artery main vessel at the RV branch bifurcation revealed that the RV branch was detected at 9 o'clock position. The true lumen of the RV branch (white arrow) was collapsed by an expanded false lumen that was presented as a high echogenic lumen (white arrowhead)
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Fig2
The angiogram showed that the RV branch was completely occluded (Fig. 2). IVUS image at the RV branch bifurcation from the RCA MV revealed a jailed first guidewire in the true lumen that was collapsed by an expanded false lumen presented as a high echogenic lumen (Fig. 2).
Schematic diagram of how to pick up the right ventricular (RV) branch true lumen. a RV branch true lumen, where jailed protection guidewire is existing in, is collapsed by the false lumen. And also the RV branch orifice is sealed by shifted plaque. b Aiming the RV branch balloon with chronic total occlusion (CTO) guidewire supported by Crusade catheter to pick up true lumen, while RV branch dilation is in the true lumen using small balloon on the protection guidewire to keep the true lumen open. c When CTO guidewire tip is pushing on the balloon through the strut, the balloon is immediately deflated. The guidewire pick up the RV true lumen in the same space of the deflated balloon
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Fig3
We decided to dilate the RV branch behind the stent strut and pick it up from inside the stent (Fig. 3).
a Right anterior oblique (RAO) lateral view. Manipulation of Gaia second guidewire with Crusade catheter during dilation for the right ventricular (RV) branch true lumen by 1.5 mm balloon. b While the tip of Gaia second guidewire was facing on the balloon through the strut, immediately balloon deflation was applied. The Gaia second guidewire could pass to the RV branch true lumen in the same space of the first protection guidewire. c Kissing balloon inflation at the right coronary artery main vessel and RV branch with 4.0 mm and 2.0 mm balloon, respectively. d Final angiogram. The RV branch was restored; the main coronary vessel also showed optimal result
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Fig4
While the RV branch balloon dilation was in the true lumen, we aimed the RV branch balloon with the ASAHI Gaia second guidewire, supported by Crusade catheter, on the MV guidewire (Fig. 4a). The wire picked up the RV true lumen in the same space of the first protection guidewire without hard resistance (Fig. 4b). Kissing balloon inflation was performed with 4.0 mm and 2.0 mm balloon for the RCA stent and the RV branch, respectively (Fig. 4c). A final angiogram showed the recanalized RV branch and optimal dilation of the RCA MV (Fig. 4d).