Shepherd’s Crook Stent Implantation in the RCA

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Shepherd’s Crook Stent Implantation in the RCA

October 6, 2011

Courtesy of Jean Fajadet, MD

Case Overview

Using a radial approach, diagnostic angiography confirmed a right dominant patient was diagnosed with a 90% diameter stenosis in the distal right coronary artery (A), compromising blood flow to the posterior region of the heart. The severe “Shepherd’s Crook” (B) in the proximal RCA and the highly stenosed lesion were the main considerations in deciding the best interventional strategy. Direct Stenting the lesion utilizing the ‘All-in-One’ Svelte Acrobat Coronary Stent system is deemed the best means for a successful intervention.

Procedural Progression

A Svelte Acrobat 3.5 x 18mm stent was selected and the 0.012” wire tip shaped. The Svelte system was introduced via 5F catheter. After successfully navigating the Shepherd’s Crook (B), the Svelte system crosses the tight lesion with the ease of a standard guidewire (C). Using the radiopaque stent markers, precision placement of the Svelte stent across the lesion is completed just prior to stent deployment.

The Svelte stent was delivered with high ATM pressure deployment utilizing Svelte’s low-compliant delivery balloon with balloon control bands (BCBs). (D) Once deployed, the delivery system was retracted proximal to the lesion for reassessment. (E) Following control angiography, the Svelte system was advanced and positioned for post-dilatation with the same delivery system balloon.

After reassessment, the Svelte system is removed and a highly patent RCA is observed in the final control  angiography (F).

Conclusion

The Svelte system was used successfully, demonstrating the flexibility and trackability of the system. Navigation of the “Shepherd’s Crook” and crossing the highly stenosed lesion were accomplished with relative ease, allowing for the successful use of the direct stenting technique. Post-dilation was accomplished without any complication or need for an NC balloon. Final control angiography indicated a patent RCA with TIMI 3 flow.

Keys to Success: 

  • Wire tip and stent flexibility facilitated successful navigation of the “Shepherd’s Crook” RCA tortuosity.
  • Low profile and trackability facilitated ease of crossing a heavily calcified, highly stenosed lesion.
  • Safe high pressure inflation with BCB protection allowed for maximal lumen gain while guarding against edge dissection.