XMK

A 63-year-old man with underlying history of hypertension, hyperlipidemia and diabetes mellitus, presented with effort angina. He had history of multivessel coronary artery disease. In 2017, PCI for RCA CTO lesion was done with ADR technique & 4 bare metal stents deployed from distal to proximal RCA. Almost all of stent segment are in subintimal space (Figure A: Pre-PCI, Figure B: Post-PCI).

Stress myocardial perfusion scan illustrated reversible ischemia in inferior, inferolateral and inferoseptal wall. (Fig-A)

Coronary angiogram result were as follow: (Figure A, Figure B & Figure C))

By the support of EBU 3.5/7F and AL 1.0/7F, advanced Sion GW & Finecross MC into epicardial collateral channel.Tried to advance SUHO-3, Sion and FielderFC GWs but failed & noted contrast extravasation.Advanced Sion black GW and MC to PDA via septal collateral channel. MC switched to SASUKE DLC.Retrograde puncture with UB3, Gaia3 & Runthrough GWs.UB3 tip was broken and left in PDA.Failed and proceeded to antegrade approach.Runthrough GW to cornus branch and antegrade puncture was done with Gaia3 & Sasuke catheter.Wire esclation to CP 12, CP 8-20 & Gaia3 GW and could advance to mid RCA.MC couldn't pass proximal RCA.Balloon anchoring in cornus branch and POBA with 1.0 mm balloon but MC couldn't cross.Tried again with FielderXTA & FielderFC which could advance to mid RCA Sequential POBA with 1.0, 1.5 & 2.0mm balloons.With Sasuke catheter, Gaia3 GW advanced to PL (Figure A)POBA with 1.5, 2.5 & 3.0mm balloons.Check IVUS and noted crushed stent in subintimal space. (Figure B)Runthrough GW to distal PDAKBI with 2.0mm & 2.5mm balloon.Deployed 3.5mm DES at proximal to mid RCA. (Figure C)PL to mid RCA was dilated with 2.5, 3.0 & 3.5mm DCBs.POT stent with 4.0 mm NCB.Optimal stent expansion & apposition by IVUS. Perforation at PL & tried to deploy covered stent but it couldn't pass proximal RCA.Covered stent dislodged & deployed 3.5mm BMS over dislodged stent at distal RCA.

We present a challenging CTO PCI case. As previously deployed stents were in subintimal space, we choose primary retrograde approach in order to recannalize true lumen. Unfortunately, attempts via collateral channels was failed. So, antegrade approach was performed with the support of micro catheter and dual lumen catheter. IVUS analysis confirmed wire position in true lumen. 1 DES was deployed at mid RCA and DCB balloon angioplasty was done for mid to distal RCA segments. Procedure was complicated with distal RCA perforation which was successfully treated by stent.