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CASE20191021_007
| CORONARY - Chronic Total Occlusion | |
| Management of the Resistant CTO | |
| Yao Chang Wang1 | |
| Cheng Hsin General Hospital, Taiwan1, | |
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[Clinical Information]
- Patient initials or identifier number:
Mr. Chen
-Relevant clinical history and physical exam:
76 years old gentleman is a known case of hyperlipidemia. He had a history of old myocardial infarction and received stenting in left main coronary artery and right coronary artery. This time , he suffered chest tightness intermittently for 2 months. Thallium 201 scan revealed ischemia in the inferior wall and coronary angiography showed total occlusion of the stent in the right coronary artery. So he was admitted to perform per cutaneous intervention of the right coronary artery.
-Relevant test results prior to catheterization:
Thallium 201 perfusion scan revealed ischemia in inferior wall ( the right coronary territory ) and the echocardiography showed preserve systolic function of the left and right ventricles.
- Relevant catheterization findings:
Coronary angiography revealed the luminal irregularity in the stent in left main coronary artery and the proximal portion of the left ascending coronary artery.The left circumflex artery is patent . 75% stenosis in the right coronary artery and chronic total occlusion of the right coronary artery.
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[Interventional Management]
- Procedural step:
LMCA was engaged with JL3.5/5F diagnosticcatheter and RCA was engaged with AL1/7F guiding catheter. The lesion was tried to crossed with Runthrough and Gaia 1st GW with the assistance of Finecross catheter butfailure. Finally , the lesion was crossed throughwith Gaia 2nd GW with the assistance of Finecross catheter. But Finecross cannot cross through thelesion site.The lesion was then dilated with Trek 1.2/6 and 1.2/8 balloon at maximal pressure 12-14atm. But the microcatheter still cannot advance, so we changed to Turn Pike gold and tried for furtheradvance but failure. So we use Conquest Pro to findanother pathway and was easily introduced to distal RCA. The Finecross can advance to distal portion and and changed to Runthrough and was advanced to distal RCA. We performed sequential balloon dilatation from the distal to proximal portion of RCA . Follow up angiography revealed jailingof PDA due to the dissection flap, so we rewired Fielder GW to the PDA. Thewhole lesion was checked by IVUS whichrevealed undersizing of the previous stent. wedeployed a Synergy 3.0/48mm DES from PDAto RCA-M and was overlapped with another Synergy 3.5/48 from RCA-M to RCA-P .The whole lesion was post dilated with Trek4.0/15mm BC at maximal pressure 18atm.
 HSIEH_P_(S2_F1-126).avi ._HSIEH_P_(S24_F1-95).avi HSIEH_P_(S92_F1-104).avi- Case Summary:
The resistant CTO is defined when the guide wire is successfully crossed the CTO lesion but it is impossible advance to advance any device or balloon over the wire. Several strategies had been proposed including (1) increased guide catheter support ( deep guide intubation, used guide catheter extension , used anchor techniques) and (2) lesion modification ( Use various catheter including Tornus, Corsairs & Turn pike gold, laser coronary athrectomy and rotational athrectomy). Flow chart of resistant CTO in Cheng Hsin , after guide catheter support , lesion modification with 1.0mm balloon dilation followed by rotational athrectomy and used parallel wire technique in resistant instent CTO.
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