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CORONARY - Chronic Total Occlusion
Intravascular Ultrasound Guided Retrograde Direct Guide-wire Re-entry Of Left Anterior Descending Artery Chronic Total Occlusion
Ivan Tsang1, Raymond Chi Yan Fung2
Princess Margaret Hospital, Hong Kong, China1, Grantham Hospital, Hong Kong, China2,
[Clinical Information]
- Patient initials or identifier number:
Mr L
-Relevant clinical history and physical exam:
Mr L was a 72 years old chronic smoker with history of diabetes, hyperlipidaemia, hypertension and gout. He started to have exertional angina since early 2019 with a CT coroangiogram done in 7/2019 showing significant LAD and RCA disease. Physical examination was unremarkable except the finding of LVH.
-Relevant test results prior to catheterization:
Electrocardiogram showed sinus rhythm, left ventricular hypertrophy, atrial bigeminy and Q wave over inferior leads.
Echocardiogram showed severe hypokinesia over LAD and RCA territories and left ventricular ejection fraction of 38%. There was also mild mitral and tricuspid regurgitation.
Blood tests showed normal renal function and complete blood picture
- Relevant catheterization findings:
Coroangiogram was done on 4/9/2019. The left main stem was normal. The proximal LAD was a CTO with collateral blood flow mainly from the conus branch of RCA and also some from PDA and LCx. The LCx was mildly disease. The RCA was diffusely diseased from proximal to distal. The ostium of PLV branch was also subtotally occluded.
AP cranial.wmv
RAO caudal.wmv
[Interventional Management]
- Procedural step:
The first PCI to RCA was done on 4/9/2019 with Xience Sierra 2.5x38 to dRCA-PDA and Xience Expedition 3.5x48 to o/mRCA.
The second stage PCI to LAD was performed on 21/11/2019. LM was engaged with 7F EBU 3.5 (trans-femoral) and conus branch was engaged with diagnostic Tiger II catheter (trans-radial). Ramus branch was wired with Runthrough guidewire and LAD CTO stump was identified with IVUS. Proximal cap was punctured with Conquest Pro 8/20. Corsair Pro was advanced but failed to wire the CTO body with Gaia 2nd and Pilot 200.
Antegrade approach was abandoned due to uncertain vessel course. RCA was engaged with 7F AL 0.75 (trans-radial) and then wired with Runthrough supported by Turnpike LP. Attempted to wire septal channels from PDA but unable to find a good channel. Conus was then wired with Suoh 03 with Turnpike LP. Attempted to directly wire CTO distal cap with Gaia 2nd / XTA but failed due to acute band. Distal LAD was wired with Sion and Sasuke dual lumen catheter and this time able to puncture the distal cap with Gaia 2nd. Gaia 2nd successfully crossed the CTO. After that the microcatheter was switched back to Turnpike LP. IVUS in the LM showed the guidewire entry point was right at ostial LAD. Retrograde wire and microcatheter were successfully passed into the antegrade guiding catheter with the help of Guideliner. It was changed to RG3 and externalized. The rest of the procedure was performed as usual with the implantation of Xience Sierra 2.0x24 and 2.75x24.
bilateral injection.wmv
tip injection at conus branch.wmv
- Case Summary:
We completely revascularized the patient firstly the RCA and secondly the LAD. The LAD CTO PCI was a complex procedure in which the proximal part of the occluded segment was very hard leading to the failure of antegrade approach. The retrograde procedure was also challenging in terms of the wiring of the conus branch and also puncturing the distal cap at an acute band with the support of a dual lumen catheter. The true and optimal position of the retrograde wire was further confirmed by IVUS inserted in an antegrade manner. The patient was discharged from our hospital the next day after the procedure. His condition was stable during our out-patient clinic follow up.
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