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CASE20191031_042
| CORONARY - Chronic Total Occlusion | |
| Tiger and Bear: The Dangun Legend | |
| Ganapathi Palaniappan1, Kumara Gurupparan Ganesan1 | |
| National Heart Institute, Malaysia1, | |
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[Clinical Information]
- Patient initials or identifier number:
KA
-Relevant clinical history and physical exam:
A 56 years old gentleman with underlying DM, hypertension, hyperlipidemia, IHD and IDCM (EF 32%), had a history of acute myocardial infarction in November 2018 and was successfully thrombolysed with IV streptokinase in a rural hospital. He was referred to our center for coronary angiogram (CAG). His CAG shows CTO of LAD with collateralsupply from RCA. Attempt to cross LAD failed. Procedure was abandoned and patient was treated medically.
-Relevant test results prior to catheterization:
Patient remained symptomatic; his Technitium scan shows under-perfused but viable myocardium of LAD territory. Decided for re-attempt of CTO LAD. J-CTO score of 3.
- Relevant catheterization findings:
CAG shows CTO of proximal LAD with collateral supply from RCA, mild disease of proximal RCA (dominant vessel) and normal LCX vessel.
 pre caudal.mpg pre cranial.mpg rca pre 2.mpg |
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[Interventional Management]
- Procedural step:
Initially antegrade wire escalation strategy utilized under IVUS guidance with SION wire. However, it was unsuccessful. We switched to retrograde approach. It took total of 4 guidewires, 11 micro-catheters with multiple complex techniques, and a total of 4 hours 30minutes to successfully cross the lesion. Total amount of radiation dose was 2210 mGY, and total contrast used is 200ml.
successful septal surfing.mpg successful cross 2.mpg RENDEVOUZ technique.mpg- Case Summary:
We managed to perform a successful retrograde CTO intervention despite spending 4 hours and 30 minutes. Perseverance while taking patient safety into account is the secret of this success. As the legend of Dangun; one should not give up as the tiger, but instead one will attain success if one continue to strive with the perseverance of the bear.
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