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TCTAP C-080

A Challenging Case Report: Retrograde Approach to Overcome Long CTO

By ChaoWen Hsueh

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Presenter

ChaoWen Hsueh

Authors

ChaoWen Hsueh¹

Affiliation

China Medical University Hsinchu Hospital, Taiwan¹,

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TCTAP C-080

Coronary - Complex PCI - CTO

A Challenging Case Report: Retrograde Approach to Overcome Long CTO

ChaoWen Hsueh¹

China Medical University Hsinchu Hospital, Taiwan¹,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

A 65 year-old male came to our hospital due to chest tightness on exertion for weeks. His two older brothers also had coronary artery and took PCI before.

Past history :

Coronary artery disease s/p PCI years ago

Dyslipidemia

Cath history

2008/11

LCx M/3-D/3: Taxus Liberte' 3.0/28, 2.75/28mm

OM1: Taxus Literte' 3.0/16mm

LAD P/3-M/3: Taxus Liberte' 2.75/28, 2.5/16mm

RCA D/3 to PDA: Taxus Literte' 2.75/32mm

2013/8

Diffuse ISR: POBA

Relevant Test Results Prior to Catheterization

Thallium 201 scan was arrange and the result showed strong positive.ECG showed no specific findings

Relevant Catheterization Findings

Retrograde approach:Sion wire with broken-tip, loaded in Corsair Pro MC 150cm, was advanced into the 4th septal branch. Suoh03 wire reached PDA and m-RCA. Gaia II wire entered CTO body. Reverse CART proximal CTO cap was dilated. Retrograde Gaia II wire successfully crossed CTO, proximal RCA and reached aorta. Guideliner extension catheter was not used after successfully advancing retrograde Gaia II wire into antegrade. RG3 300cm Wire externalization was achieved.

Interventional Management

Procedural Step

2. Retrograde approach:Sion wire with broken-tip, loaded in Corsair Pro MC150cm, was advanced into the 4th septal branch smoothly, but couldn't crosscorkscrew septal channel.Corsair Pro MC tip injection showed several ambiguouschannels. Suoh-03 wire couldn't entered the main collateral channel. Afterrepeated tip injection and several attempts, Suoh03 wire successfully crossedcorkscrew-like septal channel, reached PDA and went into m-RCA. RetrogradeCorsair Pro MC was gradually advanced into m-RCA by careful rotation. XT-R wirecouldn't cross CTO. Gaia II wire crossed distal CTO cap and entered CTO body,but couldn't kiss the antegrade wire at proximal CTO cap. Reverse CART wasperformed and proximal CTO cap was dilated with Euphora 2.0/20 6-12atm x2.Retrograde wire couldn't cross CTO and RVB ostium was compromised. RVB TIMI 3flow was restored by Euphora 2.0/20 8atm dilatation although type B dissectionat osiutm. Reverse CART was performed again with Trek 2.5/12 balloon 8-12 atm.Retrograde Gaia II wire successfully crossed CTO, proximal RCA and reachedaorta. Guideliner extension catheter was not used after successfully advancingretrograde Gaia II wire into antegrade guiding catheter by adjusting GCdirection. Retrograde Gaia II wire was trapped within antegrade GC by Trapperballoon, then retrograde Corsair Pro MC crossed CTO and gradually reachedantegrade GC by great effort. RG3 300cm Wire externalization was achieved

Case Summary

Septals in retrograde PCI is the most frequently used in retrograde PCI for CTO’s of LAD or RCA. In most cases, the septal is much straight forward course than epicardial channels. Variable channel size & diameter is often obtained. However the septals could be very tortuous too. Dry tamponade could be happened.

E-Case

TCTAP C-080