63 years old female with past history of DM, HT, & hyperlipidemia was admitted for chest pain and NSTEMI as diagnosed by cardiac enzyme rise. Physical exam was unremarkable.  Echo showed normal LVEF. DAPT loaded and proceeded with PCI.
normal LV function.mp4

Cardiac enzyme was raised, ECG inferior leads T-wave inversion, echocardiogram showed normal LVEF without significant valvular lesion.

Access Right Radial 6Fr sheath.  Tiger diagnostic catheter to LCA and RCA. LCA: distal left main 30% stenosis, middle left anterior descending 80%, left circumflex 50%. RCA: dominant right coronary artery with 80% stenosis from proximal to middle segment. RCA lesion considered culprit as ECG finding of inferior leads TWI and dominant right system.
LCA AP cranial.wmv
RCA diagnostic.wmv

Decision to intervene RCA as culprit vessel. 6Fr IL 3.5 guide but complicated with ostial RCA spiral dissection, which extended into PDA. Patient complained of chest pain and developed hypotensive at this point.  IABP was promptly inserted and her BP stabilized.  Attempted to wire the RCA with rinato prowater (Asahi Intecc, Japan) wire to distal RCA, but IVUS (Phillips Volcano, USA) showed that the wire was actually in the false lumen.  We attempted parallel wiring with a third ostial wire to prevent guiding engagement in to the false lumen, but was not successful. We then performed the STRAW technique applying continuous suction over Finecross (Terumo, Japan) microcatheter in order to collapse the false lumen to facilitate wiring into the true lumen but was unsuccessful.  Finally, we utilized the intimal calcium at the mid-RCA as the anchoring point and successfully reentered distal true lumen with a Fielder XTA wire (Asahi Intecc, Japan).  Distal true lumen was confirmed by IVUS as well as contrast injection via Crusade (Kaneka, Japan) Dual-lumen catheter.  After true lumen confirmation, usual PCI proceeded with final implantation of 2 overlapping drug-eluting stent.  Distal RCA small dissection left and resolved on repeat angiography 5 days later during stage PCI to LAD.
RCA dissection.wmv
STRAW.wmv
Final shot LAO cran.wmv

In conclusion, this is a case of guiding catheter induced right coronary dissection, failing multiple attempts with various methods to wire the RCA true lumen and finally succeeding with intimal calcium anchor re-entry to distal true lumen.  This case demonstrated various techniques to overcome the difficulties of true lumen wiring the in case of ostial dissection, and highlighted the importance of intracoronary imaging in both confirming the position of the wire as well as guiding the procedure.