Lots of interesting abstracts and cases were submitted for TCTAP 2023. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

TCTAP C-088

Menacing CTO and Calcium in Severe LV Dysfunction- A Chip Case at Every Step

By Richa Sharma

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Presenter

Richa Sharma

Authors

Richa Sharma¹

Affiliation

Shri Mahant Indiresh Hospital, Dehradun, India¹,

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TCTAP C-088

CORONARY - Complex and Higher Risk Procedures for Indicated Patients (CHIP)

Menacing CTO and Calcium in Severe LV Dysfunction- A Chip Case at Every Step

Richa Sharma¹

Shri Mahant Indiresh Hospital, Dehradun, India¹,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

660year old hypertensive malep/w c/o AOE II, DOE II since 2-3yrs, increased since one month to NYHA III.O/e , Patient was hemodynamically stable and on optimal medical therapy.Echo s/o LVEF 37%, LCx and RCA territory severely hypokinetic with posterior wall being aneurysmal.Pt was advised for CAG under informed consent.

Relevant Test Results Prior to Catheterization

Stress Thallium : s/o viable RCA and LAD territories. Posterior wall was non viable.Routine blood investigations in view of complete blood count, kidney function test were within normal limits.

Relevant Catheterization Findings

CAG was done via right radial route, s/o:Mild plaquing in LMCA shaft; Proximal to Mid LAD long lesion with 90% stenosis, heavily calcific vessel; LCx 100% CTOMid RCA 100% CTO (retrograde collaterals from LAD to RCA) Since stress thallium s/o viable LAD & RCA territories, decision to revascularize the same.
PLAN A- antegrade approach with a CTO wire upfront with microcatheter supportPLAN B- retrograde approach after first revascularizing LAD

Interventional Management

Procedural Step

PTCA toRCA
B/l Femoral artery access
7F AL-1/3.5 to hook RCA
EBU 3.5/6F hooked to left system GAIA-II taken with Mizuki microcatheterWire couldn’t take torque and was bucklingWire de-escalated to Fielder XT-A. It first crossed subintimally into PLV, pulled back and crossed into PDA. This was confirmed by a retrograde shot from left system. 1.0*5 mm balloon couldn’t cross the lesionAnchor wire taken into side branch. After the support, 2.0*10mm SC balloon could now cross the lesion f/b predilation by 3.0*10mm balloon. Workhorse wire exchanged over microcatheter. 3.0*48mm DES from RCA to PDA confirmed by a retrograde shot. 3.5*48mm DES in prox to mid RCA (overlapping) deployed. Antegrade shot taken which was s/o ostial haziness due to dissection. 3.5*12mm DES from ostial to prox RCA. Ostial flaring with stent balloon. Pd with 3.5*12mm NC @ 16-20atm. TIMI 3 flow achieved with both PDA &PLV flowing.After 2months, pt came for revascularization to LAD. CAG s/o patent RCA stent. LMCA lesion progressed within 2 mos. Plan to do OCT to assess LMCA shaft disease & calcium. OCT showed deep ring calcium of more than 5mm length, calcium nodule in proximal LAD. LMCA shaft MLA-5.1mm2. So, decision to do crossover LMCA-LAD stenting.Rotablation with 1.5mm rotaburr @180rpm f/b predilation with 3.5*12mm NC @14atm. 3.5*48mm DES- prox to mid LAD. 4*20mm DES from LMCA to LAD (overlapping). Pd with 4*10mm & 4.5*12mm NC balloon. TIMI 3 flow with adequately expanded & apposed stent.

Case Summary

Assessing calcium and doing a proper bed preparation with various available modalities is extremely important for proper apposition and expansion of stent and preventing stent failure rates. Various tools to menace the tough calcium like cutting balloons, IVL, rotablation, OPN NC should be present in the cath lab while performing such a case. OCT is a better tool to assess calcium.Wirecrossing is not the only challenge in handling CTOs. In balloon uncrossable lesions, various techniques can be resorted to complete the procedure.There are various ways to dilate the undilatable lesion that can be used in CTO cases to achieve the result.

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E-Case

TCTAP C-088