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Anterograde Approach for LCA CTO Lesion
- Operator: Kenya Nasu, MD
Case Presentation
A 61-year-old male patient was admitted for abnormal electrocardiogram and echocardiogram. He had no effort chest pain and dyspnea on exertion. His coronary risk factor was current-smoking, hypertension and diabetes mellitus. His echocardiogram showed mild LV dysfunction (EF 50%) and RCA/LAD territory regional wall motion abnormality (basal inferior, mid posterior, mid anterior and apical wall). Thallium SPECT showed reversible large decreased perfusion in LAD territory.
Baseline Coronary Angiogram
  1. The left coronary angiogram showed proximal LAD CTO ( Movie 1).
  2. The right coronary angiogram showed proximal RCA 80% discrete lesion and RCA to LAD collateral G3 ( Movie 2).
Procedure
Right coronary artery was engaged with a 7 Fr AR 2 guiding catheter and left coronary artery was positioned with an 7 Fr EBU 3.5 guiding catheter through the bi-femoral approach. After anchoring balloon (Euphora 2.0 x 20 mm) at diagonal artery, we tried to pass the CTO lesion by anterograde approach using Gaia next 1 wire with Caravel 135cm microcatheter ( Movie 3). Lastly, we tried to pass the CTO lesion by anterograde approach with Gaia next 2 wire. And then, we successfully pass wire into RCA CTO lesion ( Movie 4). After advancement of Caravel microcatheter, we changed Gaia next 2 wire to Sion blue wire and performed several balloon dilatations at proximal to middle LAD using Euphora 2.0 x 20 mm and FLYDO 2.5 x 20 mm ( Movie 5). After predilatations, we deployed one Resolute Onyx stent (3.5 x34mm proximal to mid LAD, Movie 6). After stenting, we checked stent under-expansion by IVUS (Figure 1). We inflated Sapphire NC 4.0 x 10mm up to 24atm (4.4mm) at proximal LAD ( Movie 7). The final IVUS showed well appositioned stent at proximal to mid LAD (Figure 2). The final angiogram showed successful revascularization at LAD CTO lesion ( Movie 9, Movie 10).

Appendix
RCA view showing retrograde filling of LAD: Movie 11
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