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Lots of interesting abstracts and cases were submitted for TCTAP 2021 Virtual. Below are accepted ones after thoroughly reviewed by our official reviewers. Don’t miss the opportunity to explore your knowledge and interact with authors as well as virtual participants by sharing your opinion!

TCTAP C-041

Presenter

Tsuda Takuma

Authors

Tsuda Takuma1

Affiliation

Nagoya Ekisaikai Hospital, Japan1,
View Study Report
TCTAP C-041
CORONARY - Chronic Total Occlusion

How Do You Manage It?

Tsuda Takuma1

Nagoya Ekisaikai Hospital, Japan1,

Clinical Information

Patient initials or Identifier Number

N.T.

Relevant Clinical History and Physical Exam

Diagnosis: APPrior intervention:   May/2016   emPCI to #6 due to ant-AMI(#6 100%→Xience Alpine4.0/18).                       RCA#1 CTO was followed by OMT.    Apr/2018    PCI to #8(DCB)   Oct/2019    PCI to RCA-CTO was plannedCoronary Risk Factor: DyslipidemiaLaboratory findings: Cre/eGFR=1.07/ 57.0

Relevant Test Results Prior to Catheterization

Echocardiography showed EF 43%, ant/inf hypokinesis.CTCA showed long RCA-CTO over 100mm. MPI showed viability in inferior wall of left ventricular.J-CTO score was estimated as 2 (CTO length/ tortuosity).


Relevant Catheterization Findings

CAG showed CTO in proximal RCA. Characteristics of CTO entry was stumped, and CTO distal exit was bifurcation of #4-PD and #4-PL.LCA had no significant stenosis with well-developed collateral from septal branch to #4-PDA. Lcx had neither significant stenosis.
RCA-1.mov
LCA-1.mov
LCA-2.mov

Interventional Management

Procedural Step

1. 1st retrograde approach: Sion with Corsair could pass 1st septal 2. Retrograde wiring: a) UB3→Gradius could not pass CTO entry. b) Sasuke+UB3→Gradius→GradiusMGcould not also pass CTO entry. c) Balloon screening+UB3→Gradius→GradiusMG could not also pass CTO entry 3. Antegrade wiring: a) Corsair+MN3 could pass CTO entry 4. 2nd retrograde approach: a) Caravel made vessel perforation due to its movement. b) Suoh03 could pass AC channel. c) Suoh03could be navigated into #4-PD with balloon screening of #4-PL. d) Retrograde wiring(UB3→Gradius→GradiusMG) was succeeded to navigated CTO entry with balloon trapping 5. Retrograde knuckle wire: a) GradiusMG knuckle  6. Antegrade rewiring: a) Smallprofile balloon (0.85mm/5mm) could not also pass entry of CTO. b) GN3 was intentionally navigated into subintima. c) Guide-extension rCART was succeeded to externalize retrograde wire. 7. IVUS examination: a) IVUSshowed wire existed outside vessel at mid-RCA and also take shortcut for#4-PD/#4-PL bifurcation. 8. IVUS guided rewiring (3rdretrograde approach): Retrograderewiring (Gaia Next3) via septal with antegrade IVUS was performed to navigate retrograde wire into intra-plaque. 9. POBA/stenting 4 DESs were implanted. 10. Channel check AC channel perforation was successfully stopped.
PCI1.mp4
PCI2.mp4
PCI3.mp4

Case Summary

This is the case of RCA CTO with some debatable and educational discussion. In particular, IVUS guided wiring, the way of retrograde set up remained difficult and unclear point during CTO procedure. Here we all learn and share tips for overcoming tough CTO case.

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