J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 9 , N O . 1 6 , S U P P L S , 2 0 1 7 S297

Case Summary. Distal embolism can occasionally be critical when wetreat a lesion with massive thrombi. We demonstrated herein a verysimple but possessively useful embolic protection system. It mayprobably reduce medical costs and complexity of EVT procedures.

TCTAP C-210

“PTRA” with Stenting for Recurrent Flash Pulmonary Edema in aPatient with Bilateral Totally Occluded Renal Arteries

Praskas Chandra Mandal11Apollo Gleneagles Hospital, India

[CLINICAL INFORMATION]Patient initials or identifier number. Mr. KP.Relevant clinical history and physical exam. Mr.KP. 67 years-old diabetic,hypertensive,hypothyroid, smoker presented in a gasping state withdyspnoea and sweating for one hour duration. He had “CABG” 12years backs. Cardiac Troponin was not raised. Pulse-162/min. Resp-46/min. BP-220/130 mmHg. The LVS3 present. Chest -reputations(Killip Class-IV). He was intubated and ventilated with other sup-portive therapy. Clinically stabilized and extubated on 3rd day. Butdespite continuing medical therapy he developed Flash pulmonaryedema again on same day.Relevant test results prior to catheterization. Routine Laboratory Param-eters: Hb-9.8 gm%. Serurm Creatinine-5.8 mg% (Creatinine Clearance-34 ml/kg/M2). Naþ -138 meq/L. Kþ-5.1 meq/L.Cardiac Troponin-I -normal.ECG- LVH. Global ST-T changes.Echocardiography: Concentric LVH. Grade-II ‘LV’ diastolic

dysfunction. ‘LVEF’-68%. No ‘RWMA’.USG Abdomen: Bilateral renal parenchymal disease. RK-8.9 cm. LK-

8.4 cm.Relevant catheterization findings. The Renal Vascular Doppler Study:Spectral broadening with parvus et tardus wave pattern in intrarenalarteries of both kidneys suggestive of bilateral renal artery stenoseswith very poor flow.Coronary Angiography: Native triple vessel coronary artery disease.

Patent Grafts (LIMA-LAD, RSVG-D1/OM1/PDA).Renal Angiography: Totally occluded both renal arteries at their

origins.[INTERVENTIONAL MANAGEMENT]Procedural step. “PTRA” with stent to Left Renal Artery: Right FemoralAccess with 7F sheath. The RDC guide catheter. First tried with

coronary intermediate wire but failed. 5F IMA catheter used as childcatheter. Lesion crossed and pre-dilated with 3.0 x 12 mm sprinterlegend coronary balloon. Flow appeared and whole contour withnephrogram of left kidney visualized. Lesion stented with 6 x 18 mmstent. Ostium flared in high pressure. TIMI-3 flow achieved with goodnephrogram and ureterogram. An episode sevre “BP” surge withsystolic BP of 240 mmHg. Contralateral artery was not attempted.Diuresis improved from 3rd post-procedure day and serum creati-

nine improved (3.4 mg% on 7th day). Haemodialysis was stopped afterone month and for last 9 months he is off dialysis. BP well controlledand no recurrence of pulmonary edema.

S298 J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 9 , N O . 1 6 , S U P P L S , 2 0 1 7

Case Summary. Intervention in totally occluded renal arteries is highlyfeasible. Coronary ‘CTO’ hard wires can safely be used for this pur-pose. Patients with flash pulmonary edema respond very well to renalre vascularization and may be the most effective therapeutic option inpresence of critical renal ischemia. The Renal ischemia evokes strongneuro-hormonal activation which plays a central role in aetiopatho-genesis of flash pulmonary edema as well as hypertensive emergen-cies. Patients with resistant hypertension specially with hypertensiveurgencies and emergencies also got neuroendocrinal, beneficial ef-fects of renal re vascularization.

TCTAP C-211

Retrogradely Antegrade Recanalization of Subtotal Occlusion ofRight Subclavian Vein and Balloon-assisted Puncture forPacemaker Lead Insertion

Jun-Ting Liou,1 Yuan Hung,1 Wei-Shiang Lin1

1Tri-Service General Hospital, National Defense Medical Center, Taiwan

[CLINICAL INFORMATION]Patient initials or identifier number. Mrs. Min 2841126Relevant clinical history and physical exam. An 89 years-old female withhypertension and pulmonary fibrosis experienced palpitation off andon for 3 weeks. Bradycardia and hypotension developed by more beta-blocker, but soon resolved after temporary transvenous pacing.Thesick sinus syndrome (paroxysmal Af and long pause 3.9 sec) wereconfirmed.Permanent pacemaker (PPM) implantation was planned at other

hospital. The Venography: Total occlusion of left in nominate andsevere stenosis at right subclavian vein (SCV). The procedure faileddue to R’t Pneumothorax.Relevant test results prior to catheterization. The right pneumothoraxresolved soon after pigtail catheter drain, she was referred to ourhospital for PPM implantation. Another antegrade venography viaright radial vein showed subtotal occlusion of right SCV. PPM wasdeferred.Surgical approach with epicardial lead and generator in the

abdominal area was not favored because of high surgical risk. Theretrograde approach to recanalize right SCV subtotal occlusion andballoon-assisted puncture for vein access were planned.

Relevant catheterization findings. The antegrade venography stillshowed subtotal occlusion of right SCV with collateral flow.The retrograde venography showed patent right internal jugular

vein.[INTERVENTIONAL MANAGEMENT]Procedural step. The 7Fr multiple purpose GC via R’t femoral veinaccess was advanced to right superior vena cava, near subtotal oc-clusion of SCV. Retrograde venography showed no retrograde flow toRight SCV, but patent internal jugular vein.A 0.014” Fielder-Fc wire, loaded in 135 cm Corsair microcatheter

(MC), was advanced retrogradely into subclavian vein. Antegradevenography showed possible subintimal tracking and wiring out ofvessel.The wire in false lumen was withdrawn and advanced acrosstortuous collateral channel loop and slowly into proximal SCV. Thegentle wire manipulation overcame the acute angle between collateralvessel and SCV Retrograde-wire gradually crossed SCV subtotal oc-clusion by antegrade manner and was further advanced into guidingcatheter.The Corsair MC was also advanced into guiding catheteralong wire. Rendezvous technique in GC failed (Another Fielder FCwire, loaded in 130 cm FineCross MC, failed to be advanced intoCorsair MC).Externalization completed by by RG-3 330 cm wireFineCross MC crossed subtotal occlusion retrogradely along RG-3

wireFielder FC replaced RG-3 wire and was advanced into proximal SCV

along Fine Cross MCBalloon dilatation and IVUS at Right SCV subtotal occlusion were

performed and vessel sizes were evaluatedThe 3.0 x 20 mm Balloon was inflated in subtotal occlusion segmentBy aiming balloon in SCV, puncture needle penetrated balloon and

reached right SCVBalloon-assisted puncture to access SCV and PPM lead insertion

were successful.