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CASE20191014_003
| CORONARY - Chronic Total Occlusion | |
| The Path Less Travelled: Septal Loop Retrograde | |
| Abdul Ariff1, Ahmad Khairuddin Mohamed Yusof1 | |
| National Heart Institute, Malaysia1, | |
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[Clinical Information]
- Patient initials or identifier number:
Mister SJ
-Relevant clinical history and physical exam:
77 year old gentleman, with background history of dyslipidemia, had MSCT Coronaries done in 2015, which showed diseased LAD and RPDA. However, he was not keen for coronary angiogram back then as he was asymptomatic.He then presented with new angina-like symptoms for 1 month, and ECG stress test in July 2019 showed positive ischaemia at stage 3. In view of the disturbing symptoms, this time around, he is keen for coronary angiogram.
-Relevant test results prior to catheterization:
MSCT Coronaries in October 2015:
LMS: normalLAD: mild disease proximally, subtotal occlusion after diagonal 1LCx: mild calcified plaque proximally with mild luminal irregularityRCA: dominant vessel with no significant disease but PDA appears to have significant disease Echocardiogram in September 2019:EF 60%, normal chambers size, grade 1 diastolic dysfunction, TAPSE 2 cm - Relevant catheterization findings:
LMS: smoothLAD: CTO proximal segment (just at the bifurcation of septal 1), collaterals from septals and RCALCx: moderate stenosis proximal segment 40%RCA: dominant, severe stenosis RPDA 70%
 CAG Cranial.avi CAG RAO Caudal.avi CAG RCA with collaterals.avi |
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[Interventional Management]
- Procedural step:
EBU 3.5 8 Fr engaged to left main via right femoral. IVUS showed stump-less, hard proximal cap.Antegrade wire escalation approach was unsuccessful. Corsair & Asahi Sasuke as microcatheter, unable to cross lesion with Runthrough Floppy, Fielder XTR, Gaia First & Gaia Next 2. Wires kept on slipping to septal 1 & proximal cap was not penetrable.Plan changed to ipsilateral retrograde approach via septal channels.With Caravel support, Asahi Suoh failed to negotiate from septal 1 to septal 2 in view of acute angulation. Wire escalation, Fielder XTR then retrogradely penetrated distal cap and successful recanalization was achieved.Asahi SBP SH 7 Fr engaged to left main via left femoral, as antegrade catheter (ping-pong technique). Wire changed to Runthrough Floppy & advanced to antegrade catheter. Corsair then advanced to antegrade catheter with balloon trapping assistance (after failed Caravel).RG3 wire replaced Runthrough Floppy & successful externalization through antegrade catheter.Plan of using RG3 as workhorse wire was withheld in view high risk of complications & distal intervention possibility. Corsair were withdrew inside septal 2. Via antegrade catheter, Runthrough Floppy successfully wired down to distal LAD with Asahi Sasuke support.Retrograde system was removed & Rinato wired to diagonal 1 antegradely for protection.Stent Combo 2.5/33 was implanted & postdilated with Sapphire NC 2.5/12 at high pressure.
1.avi 2.avi 3.avi- Case Summary:
After failed antegrade wire escalation, septal channels were chosen for retrograde in view of good track & distal cap is just proximal to 2nd septal branch. Fielder XTR successfully negotiated the tight angle of septal branches in view of better flexibility. After recanalization, Corsair (better in tortuous lesion) able to navigate to antegrade catheter, despite Caravel having superior trackibility. After successful externalization, plan was switched to conventional antegrade wiring, as distal intervention might be needed & high risk of complications associated (LM dissection & collateral injury). Wiring was smooth, thanks to the good channel created. End result was good.
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