E-Science Station

308029

We describe a 48 year old gentleman, with underlying diabetes, hypertension and dyslipidemia. He is also a habitual smoker of 30 pack years. He was referred from a district hospital for NSTEMI, where he had initially presented with typical angina,associated with dynamic ST depression in the anterolateral leads, Q waves in leads V1-V2 and a raised troponin reading. On examination he is alert, His BP is 153/95 and pulse rate 85. Clinical examination was otherwise unremarkable.

Initial ECG at our centre showed pathological Q waves in the anterior chest leads V1-V2.  Echocardiography showed a largely normal left ventricle with an ejection fraction (EF) of 55%. There was no obvious wall motion abnormalities seen, and the valves were functioning well. Biochemically tests were also normal, and he had a fasting LDL of 4.2 mmol/L, HDL 1.3mmol/L, and HbA1c of 78mmol/mol.
ECG.docx

Angiogram and attempted angioplasty on 30/4/2019. LMS: normal; LAD: CTO with blunt but angulated proximal cap, near Diagonal branch;LCX: large dominant with mild disease, RCA: small non dominant vessel, diffuse moderate disease with collateral channels to mid and distal LAD. 
First attempt to open the proximal LAD CTO with wire escalation technique and microcatheter support failed due to multiple instances of wire passing into diagonal branch and subintimal space, thus the procedure was abandoned.
LAU Cra LAD.avi
RAO Cra RCA collaterals epicardial and tortouos.avi
5 subinitiaml wiring.avi

Second attempt at the LAD CTO on the 3/5/19, with J-CTO score of 2. Anterograde approach was still the first choice, given the very tortuous nature of the collateral epicardial channels making retrograde approach less favorable. This time we decided to employ IVUS guidance
Double femoral access followed by JR Guiding 7Fr to RCA and EBU 7Fr to LMS. A SION BLUE wire was passed into the Diagonal, with IVUS over it. Clear visual images of the proximal CTO cap were obtained from the IVUS in the diagonal. Using the IVUS to guide positioning of a stiff wire, we employed wire escalation to penetrate the proximal cap. GAIA 2nd was unsuccessful, but CONQUEST PRO 12 stiff wire was able to cross the proximal cap. We passed the stiff wire through the proximal cap under direct visualization with IVUS, ensuring no subintimal passage. CONQUEST wire successfully crossed the CTO body and distal cap, into the true lumen of the LAD
We then advanced a CORSAIR microcatheter over the CONQUEST wire through the CTO lesion, using a twisting motion. The stiff wire was exchanged for a workhorse SION BLUE wire and we reexamined the course of the wire through the LAD under IVUS
Lesion prepared with SAPPHIRE II PRO 2.0x 20 balloonStented with COMBO PLUS 2.5x33mm, and COMBO PLUS 3.0x33mm We used IVUS for post stenting assessment and the stent was well opposed, thus not further postdilation was doneFinal results were good, TIMI 3 flow with no immediate complications Radiation: 1137mGyContrast: 200ml
8 crossing the CTO.avi
Ivus penetration correct.avi
26 final shots.avi

We managed to successfully cross a CTO LAD despite a challenging proximal cap by using IVUS guidance. This allowed for a more accurate wiring of a challenging proximal CTO cap, avoiding inadvertent subintimal wiring and its potential complications such as perforation or acute vessel closure. Using the IVUS it also saved time, reduced radiation exposure and contrast usage. The procedure was completed within 34 minutes of flourotime,used 200ml of Ioporimo contrast, and radiation exposure 1137mGy. Total procedure time was 1 hour 15 minutes.
In summary, intravascular imaging modalities such as IVUS can be employed in challenging CTO lesions to increase rate of procedural success.