TFW

A 58-year-old man presented with frequent exertional angina for 2 weeks. He was not a smoker or drinker. Sedentary lifestyle. He has medical history of diabetes mellitus and dyslipidemia. He has regular follow ups with his family doctor and he was on Diamicron 80 mg bd, metformin 500 mg bd and atorvastatin 20 mg od. On examination, the hemodynamic was stable. The heart rate was 80/min and blood pressure was 130/80 mmHg. His BMI was 28. 

The baseline ECG was normal. The stress test was positive and showed horizontal ST segment depression at II, III, AVF, and V5-6. The blood investigations: Hb: 14.5 g/dL, creatinine: 77 µmol/L, total cholesterol: 5.5 mmol/L, LDL: 2.3 mmol/L, and HbA1C: 8.2%. The echocardiography showed normal EF of 73%. Normal valves and chambers sizes. The CXR was normal. 

Diagnostic coronary angiogram:1. LMT normal 2. Mid LAD artery 70% stenosis2. Proximal LCX artery 70% stenosis – giving an atrialventricular groove collateral (CC) to rPLV3. Mid RCA 100% stenosis (CTO)  J-CTO score: 1 (Clear proximalcap, lesion length > 20mm, non-calcified, non-tortuous, no previous attempt).The SYNTAX score was > 33. Recommended CABG. But patient declined CABG. Proceed for PCI.

Right and left femoral arteries were punctured. A 7Fr EBU 3.5 was used to engage LMT. JR 4.0 for RCA. Dual injection was performed. Attempted antegrade crossing using a Caravel 135 cm microcatheter (MC) and Fielder XTR guidewire (GW) but was unsuccesful. Wire was escalated to a GAIA 2^nd but failed to advance antegradely at mid RCA CTO body. Therefore, retrograde approach was attempted with a Sion wired through AV CC from LCX to rPLV via CARAVEL 150 cm MC. Distal cap was punctured with Fielder XTR, and reverse CART was performed at distal RCA. The retrograde XTR was changed to a Sion wire. The retrograde Sion was managed to be externalized to antegrade guide. However, retrograde MC was unable to cross the distal cap despite multiple attempts. The next attempt was "Tip in" method into externalized retrograde GW (in antegrade guide). Antegrade MC was successfully tipped into retrograde GW. Unfortunately, the antegrade MC also failed to cross CTO body antegradely by tracking along the retrograde GW. After multiple failed attempts to cross antegrade and retrogarde MC through CTO body, decided to leave the retrograde GW into the distal cap as a marker wire and to attempt antegrade crossing. Fortunately, antegrade GAIA 2nd was managed to cross CTO body into PDA. Subsequent balloon angioplasty was done using NC balloons and two EES were implanted with good result and TIMI 3 flow. The LCX and LAD lesions were subsequently treated by a stage procedures. 

CTO PCI can be challenging at each and every step. A careful planning, hybrid approach, and awareness of different techniques and tools to overcome challenges and avoid complications are key to success.