The "Five-in-Seven" Guiding Technique to Overcome Proximal Coronary Tortuosity During Primary Percutaneous Coronary Intervention

cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. A 61-year-old man was admitted for progressively accelerating chest pain during 12 hours. An electrocardiogram showed ST segment elevation of about 2 mm in leads II, III, and aVF. Left coronary angiogram showed normal coronary arteries. Right coronary angiogram showed distal right coronary artery (RCA) “culprit” lesion just before the posterodescending and posterolateral bifurcation, but the mid RCA showed severe tortuosity (Fig. 1). Primary percutaneous coronary intervention (PCI) was performed using a 6 Fr XBRCA guide catheter (Cordis, Warren, NJ, USA) and a Runthrough NS (Terumo, Tokyo, Japan) guide wire. Predilation of culprit lesion was performed using 2×20 mm balloon inflated up to 8 atmospheres (Fig. 2). Attempted delivery of a coronary stent was unsuccessful due to excessive tortuosity of the mid RCA. We changed the guiding catheter to a 7 Fr Amplatz Right 1 (Cordis, Warren, NJ, USA), but stent passage failed again, despite use of a buddy wire technique. Finally, we used a Choice PT Extra Support guide wire (Boston Scientific, Natick, MA, USA) with a 7 Fr Judkins Right (JR4) (Cordis, Warren, NJ, USA) guiding catheter and performed an extra deep intubation using