Femoral access was obtained with a 6 Fr sheath. PCI of the LAD lesion was attempted using a JL4 6 Fr guiding catheter and the left main was engaged. Unsuccessful attempts were made to cross the lesion using a 135 cm microcatheter and wire.
The wire was then switched to a 6 Fr wire which engaged the proximal cap of the LAD lesion, however any advancement of the wire resulted in the guide backing up, suggesting that it was not providing adequate support. To address this, the guide was changed to an 8 Fr with a 7 Fr and a 135 cm catheter with a 6 Fr wire. This was able to successfully cross the lesion with an antegrade wire escalation strategy.
Once the catheter was delivered across the lesion, the 6 Fr wire was changed to a ViperWire Advance® Guide Wire. At this point (with some difficulty) the catheter was removed and orbital atherectomy was performed with six passes on low speed using the Diamondback 360 Coronary OAS. Preparations were then made for stent expansion.
The stent expansion was verified using a low pressure dilation (4 atm) of a 3.0 x 15 mm Sapphire® II PRO balloon. Optical coherence tomography demonstrated adequate stent position, showing a 3.0 mm distal reference and 3.25 mm proximal reference. After a pre-dilation balloon expanded at low pressure, a 3.0 x 30 mm drug-eluting stent (DES) was delivered across the lesion and deployed. The stent was then post-dilated with a 3.25 x 15 mm balloon with an excellent result.