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TCTAP C-078

When It Seems Hopeful .. A Full Time Attempt Antegrade CTO

By Ramy Mohamed Atlm, Salma Elshokafy

Presenter

Salma Elshokafy

Authors

Ramy Mohamed Atlm1, Salma Elshokafy1

Affiliation

Tanta University Hospital, Egypt1,
View Study Report
TCTAP C-078
Coronary - Complex PCI - CTO

When It Seems Hopeful .. A Full Time Attempt Antegrade CTO

Ramy Mohamed Atlm1, Salma Elshokafy1

Tanta University Hospital, Egypt1,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

MaMal   Male  patient, aged 62 years old , Heavysmoker , not known to be Diabetic or Hypertensive, Dyslipidemic.( LDL 220 ) .
Cardiachistory of  Ischemic heart disease  one year ago with recurrent attacks of typical anginal pain refractory to medicaltreatment .
Generally : No signs or symptoms ofheart failure Local ex: Audible HS with no addedmurmurs  Bl pr : 100 / 68
HR : 72
RBS : 145

Relevant Test Results Prior to Catheterization

ECG: Normal sinus rhythm with ST Depression and T wave inversion in inferior leads
ECHO: Ischemic heart disease with average  systolic function , RSWMAs in the form of (Apico-inferior , mid and basal inferior and infero-septal wall hypokinesia ) ,        with moderate  mitral valve incompetence

Relevant Catheterization Findings

LM : Normal vessel bifurcating into LAD and LCX.
LAD : Atherosclerotic vessel with no significant lesions .
LCX : Atherosclerotic vessel with proximal significant stenosis . 
RCA : Atherosclerotic vessel with long proximal to midsegmentchronic total occlusion receiving collaterals from left system


Interventional Management

Procedural Step

Our strategy was to go for PCI LCX which was done successfully with one DES , then trial PCI to CTO RCA antegradely first through( AWE or ADR ) and if failed we will try to go retrograde through septal collaterals.Engagement of RCA with 7F AL 1 guiding catheter ,Wiring of RCA with BMW wire followed by MC advancement then AWE tried first with Fielder XT , GAIA II , GAIA III  withsupport of corsair MC but failed. So, ADR Was decided with ( base , knuckle)  , Base>> ( pilot 50 + 3x20balloon) & Knuckle >> ( pilot 50 ) but failed to cross
But due to  weak guiding support , we decided to balloon anchor in RV branch using BMW and 2.25*15 balloon together with power knuckle using inflated balloon 3x20 over pilot 50 and corsair MC over knuckled fielder XTA but also failed to cross , So we exchanged Fielder XTA with knuckled Fighter wire which succeeded to cross the CTO segment true lumen that was confirmed with dual injection that showed also big occluded PDA branch, So another Pilot50 wire was advanced to PDA through dual lumen MC Nhancer Rx with successful passage of wire into true lumen,then predilatation of PDA with 2.25 * 15balloon & Sequential predilatations to RCA was done by 2*20 ,, 2.25*20balloons with good distal run off , followed by stenting of RCA distally with3.5*38  DES & another 4*48 stent was deployed ostealy overlapping with the previous one and final post dilatation to the deployed stents with 4* 20 with good final result

Case Summary

Detailed understanding of angiogram and procedural planningis fundamental to successful CTO procedure and reduce difficulties through the procedure .The antegrade route should generally be considered as theprimary approach; however prior to all CTO procedures it is essential to assesthe eligibility of the lesion  for a retrograde approach in order to be preparedto change the strategy.Choosing the right guiding catheter is very important forsupport .AWE remains the predominant strategy for crossing short CTOsof lower complexity. But in cases of complex CTOs, an ADR strategy is a safeand effective alternative.