TP

60 year old gentleman, with diabetes and hypertension. Admitted for NSTEMI with recurrent VT. Coronary angiogram showed severe 3VD, with CTO proximal RCA. Poor heart function with EF 26%, with moderate MR from echocardiogram. Cardiac MRI showed all 17 segments are viable. Patient was referred for CABG, however was declined surgery. Electrophysiology team proceeded with VT ablation, followed by single chamber ICD implantation. Patient is then planned for PCI to CTO RCA, followed by PCI to LAD.

ECG: Sinus rhythm, Q wave inferior leads, Poor R wave progressionECHO: Ejection Fraction 26%, Tricuspid Annulus Plane Systolic Excursion 1.6cm, Mild Mitral Regurgitation / Tricuspid RegurgitationCardiac MRI: Ejection fraction 19%. Normal iRVEDV with increased iRVESV and reduced ejection fraction. Subendocardial myocardial infarction at the basal to apical anterior, lateral and inferior walls as well as the apical septal wall – LAD, LCx and RCA territories; viable.

LMS : SmoothLAD : Proximal-mid stenosis 70-80%LCX : Small, ostial-distal diffuse stenosis 70-80%RCA : Dominant, proximal stenosis 80-90%, followed by CTO segment. Collaterals from LAD.
01 - RCA LAO.mp4
02 - RCA Cranial.mp4
04 - Diagnostic Left System.mp4

Right radial & right femoral approach, both with 6Fr sheath. Short AL 1 6Fr to RCA (RRA) & EBU 3.5 6Fr to left system (RFA). Attempted to cross CTO antegradely with Caravel support & Fielder XT, Cross IT 200, Gaia 2^nd, Conquest Pro & Conquest Pro 12. However, it was unsuccessful as wire kept going to subintimal space.Strategy changed to retrograde approach, via septal channel. Finecross 150cm with Runthrough Floppy to 3^rd septal, however, no communication to distal RCA via microcatheter contralateral injection. Changed to 2^nd septal approach. Fielder FC via Finecross went through 2^nd septal, able to advance to distal RCA. However, unable to penetrate the proximal cap.Decided to change strategy to combination of Reverse CART & Knuckle wire technique with Fielder XT wire & POBA with Mini Trek 2.0x12 at 6 ATM. Knuckled Fielder XT wire dissected the artery to proximal cap CTO & advanced to proximal RCA with Reverse CART technique.ONE SNARE 120cm was used to snare the Fielder XT to RCA antegrade catheter. Retrograde Finecross was advanced to RCA catheter. Exchanged to 330cm RG3 wire & wire was externalized. Caravel was advanced antegradely to proximal RCA & changed to Runthrough Floppy wire. Left system was removed.Sequential predilatation done, up to scoring balloon 2.75/15 at 18 ATM. Stented with 3 DES with 2.5/48 at dRCA, 3.0/48 at mRCA & 3.5/38 at pRCA. Ended with postdilatation with NC 3.0/15 & 3.5/15 up to 22 ATM.
PCI 01 - Knuckling.mp4
PCI 04 - Snaring.mp4
PCI 05 - Final result.mp4

This is a CHIP procedure, in view of poor EF, recent VT & severe 3VD. Difficulties in antegrade include ambiguous proximal cap & poor visualisation of artery course. The proximal cap proved to be hard, as it was uncrossable even with stiff & heavy tip wire. Suitable septal channel was found via contralateral microcatheter injection & Fielder FC is a good wire for septal tracking. Hybrid approach of Reverse CART (reentry) & knuckle (dissection) is favourable in view of proximal cap ambiguity, poor target & long lesion. Polymer jacketed tapered wire is favoured for knuckling. Externalization was made easy with snaring method, at the soft tip of wire to prevent kinking.