Successful PCI for CTO Lesion with "Parallel Wire Technique"

- Operator : Etsuo Tsuchikane

Successful PCI for CTO Lesion with "Parallel Wire Technique"

- Operator: Etsuo Tsuchikane, MD

Clinical Presentation

A 64 year-old man was admitted for sudden chest pain and dizziness at rest. His coronary risk factor was dyslipidemia. Baseline ECG finding showed ST segment depression in inferior leads. Echocardiography revealed mild LV dysfunction (LVEF=48%) with akinesia in apex and mid-septal wall and severe hypokinesia in inferior wall. Serum cardiac enzymes were also elevated. On the next day, we performed coronary angiogram which showed a diffuse near-total occlusion with thrombus at the middle RCA, chronic total occlusion (CTO) with TIMI 0 flow at proximal LAD without stump at the bifurcation of diagonal branch, and diffuse tight stenosis at proximal to distal LCX (Figure 1, Figure 2, Figure 3). The culprit lesion of middle RCA and diffuse LCX lesion were treated with 3.5 X 30mm Endeavor stent and 3.5 X 33mm Cypher stent successfully (Figure 4, Figure 5). After then, we planned to perform staged approach for the residual CTO lesion of proximal LAD.

Baseline Coronary Angiography

1. Right coronary angiogram showed no significant stenosis with patent middle RCA stent (Figure 6).
2. Left coronary angiogram and simultaneous contralateral right coronary angiogram revealed diffuse CTO with TIMI 0 flow at proximal LAD and grade 2 collateral from RCA (Figure 7, Figure 8, Figure 9). Diagonal branch also showed significant narrowing and stent of LCX was patent (Figure 10).

Procedure

Left coronary ostium was cannulated with an 8 Fr EBU 3.5 catheter and right coronary artery was engaged with 6 Fr Judkin catheter for contralateral angiogram. Initially, a Fielder guidewire inserted into the diagonal branch (Figure 11). For the LAD total occlusion, firstly, a Rinato wire was advanced. The first guidewire passage failed and entered into the subintima (Figure 12). Thus, another guidewire of Miracle 6 was used to cross the lesion for the parallel wire technique leaving the first wire in place (Figure 13). However, the Miracle 6 guidewire could not cross into the distal true channel, so it was changed to a Conquest pro guidewire. The Conquest pro guidewire appeared to cross total occlusion (Figure 14). After verifying the position of this guidewire, the first Rinato wire was removed. Then, pre-dilation was performed at proximal to middle LAD with 1.5 X 20mm Ryujin balloon (Figure 15). Angiography showed sustained diffuse narrowing of the LAD lesion (Figure 16). After we changed Conquest pro guidewire to Rinato guidewire, further dilation was done at proximal to distal LAD with a 2.5 X 15mm Sprinter balloon (Figure 17). After that, a 3.0 X 28mm Taxus Liberte stent (by 12atm, 3.20mm) was implanted in the proximal to middle LAD (Figure 18). Then, additional post-dilation was performed with a stent balloon (Figure 19, Figure 20). For the residual diagonal lesion, a final kissing balloon was performed with a 3.0 X 15mm Ryujin balloon (up to 10atm, 3.15mm) in the LAD and another 2.5 X 15mm Sprinter balloon (up to 10atm, 2.59mm) in diagonal branch (Figure 21). Final left angiogram showed good results (Figure 22) and IVUS evaluation revealed that the diffuse narrowing of distal LAD was due to negative remodeling.

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Comments

  • Andrey Maltsev 2007-01-13 Very interesting case and good final result. The good example of correct staged approach in complex multivessel disease. The only question is- why you decided to use 8F guiding catheter? Kissing balloon final angioplasty might be performed through 7F or even 6F guide. EBU tip configuration provides excellent support with any diameter. Did you considered coronary angiography at follow-up? If yes

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