PCI in the angulated or tortuous lesion
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Editors-In-Chief: C. Michael Gibson, M.D., Alexandra Almonacid M.D., and Jeffrey J. Popma M.D.
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Overview
Severe tortuosity and moderate-to-severe calcification have long been identified as significant predictors of procedure failure, as well as worse clinical outcomes.
Angulated Lesions
- Balloon angioplasty of highly angulated lesions is associated with an increased for risk coronary dissection.
- In the settings of coronary stenting, angulated lesions represent a challenge due to the inability of delivering the stent to the stenosis and straightening of the arterial silhouette after stent implantation that may predispose to the presence of stent fracture.
- Vessel curvature at the site of maximum stenosis should be measured in the most unforeshortened projection using a length of curvature that approximates the balloon length used for coronary dilation.
Goals of Treatment
In the treatment of angulated and tortuous lesions, the main goals include successfully delivering the equipment, avoiding complications, and maximizing procedural success. Complications to avoid include vessel perforation, dissection, and premature stent deployment. Procedural success includes the restoration of normal epicardial flow and myocardial perfusion.
Treatment Choices
Guiding Catheter
There are specific guiding catheters that may be selected so that coaxial alignment may be optimized. For instance, larger guiding catheters (8 French) offer improved support. Additionally, the material composition of the catheter is also important, as the material affects torque control, kink resistance, risk of vessel trauma, and stiffness. Different catheters can also be used depending on whether you are working with the left or right system. Extra backup (XB) guiding catheters in the left coronary system, and Ampltaz left (AL) guiding catheters in the right coronary system, can provide improved support. However, these catheters can increase the risk of guide trauma to the proximal vessel, so extra care must be taken.
Guidewire
Conventional 0.014-inch guidewires are often sufficient when treating angulated and tortuous lesions, but other options may offer distinct advantages. For instance, stiffer-tip guidewires offer a greater ability to manipulate the tip, while tapered-tip guidewires may be useful if the wire prolapses away from the lesion. Although stiff wires are better able to track balloons to lesions than flexible wires, they may handle poorly and be more likely to result in an adverse event. Since extra-support wires have a stiffer shaft, they may help straighten tortuosity and ease movement. However, extra-support wires can also increase the likelihood of vessel pleating. Thus, extra care should be taken depending on the chosen type of guidewire.
It is possible to first cross the lesion with a less rigid wire and then exchange it for a heavy-duty wire through a balloon lumen. This can be accomplished in an over-the-wire (OTW) system or an intracoronary catheter such as an Ultrafuse or Transit catheter. In some circumstances, the addition of a second guidewire across the stenosis, commonly referred to as a “buddy wire”, will aid in the delivery of the device. If a buddy wire is used, a wire of different stiffness and lubricity from the original wire is usually chosen.