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 planned
Coronary Risk Factor: DyslipidemiaLaboratory findings: Cre/eGFR=1.07/ 57.0
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).
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
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.
4 DESs were implanted.
10. Channel check
AC channel perforation was successfully stopped. PCI1.mp4 PCI2.mp4 PCI3.mp4
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.