Case

Antegrade Approach for mRCA CTO lesion

- Operator : Etsuo Tsuchikane

Antegrade Approach for mRCA CTO lesion
- Operator: Etsuo Tsuchikane, MD
A 46-year-old man was admitted to our hospital for treatment of CAD. He had a history of DM, hypertension, smoking and dyslipidemia. Treadmill test was negative and trans-thoracic echocardiography showed normal LV systolic function without wall motion abnormality (EF=66%).However, coronary CT angiography revealed mRCA total occlusion.
Baseline coronary angiogram
1. A right coronary angiogram showed total occlusion of mRCA with collateral flow from to LAD( Movie 1).
2. A left coronary angiogram showed mild diffuse narrowing of pLAD( Movie 2).
Procedure
Right and left coronary artery was cannulated with a 7 Fr AL 1 SH guiding catheter and a 5Fr JL 3.5 diagnostic catheter, respectively. By using 0.014Ħħ Fielder XT and 0.014Ħħ Ultimate wire were tried to pass through pRCA CTO lesion antegradely (Figure 1) and passed successfully (Figure 2). Several sequential balloon dilatations with Maverick 1.5*15mm and 2.5*15mm were performed (Figure 3, Figure 4).After IVUS examination, We deployed PROMUS Element 2.5 * 32 mm and PROMUS Element 3.0 * 38 mm stent (Figure 5, Figure 6, Figure 7). After deploying stent, high pressure ballooning with Quantum 3.5 * 15mm was done. The final angiogram showed well positioned and expanded stent with good distal run-off flow ( Movie 3).

Comments

  • Joao Alexandre Farjalla 2011-12-15 This patient should be managed medically. Whats the benefit for that cost in a patient with normal ventricular function and tradmill test without isquemia?
  • Zening Jin 2011-12-16 I agreed with Joao's opinion. No ischemic evidence, no intervention.
  • carlos fernandez pereira 2011-12-17 Dear Etsuo and Park's Summit MD team: thank you for share with us with this excellent case,as usual in this page . just a few questions that I would like to know: 1-what do you think to always use of OTW balloons with first approach? 2-how do you choose the wire for a CTO?for example in what cases do you prefer choice pt,cross it 100,miracle 3,and so on. 3-In this case did you use IVUS after to schedule what stent use or is your usual approach? 4-In all DES use you prefer to dilate after with a non compliant ballon,which is a practice that I like. best regards
  • Jingjin Che 2011-12-17 Congratulation for this good case! But how do you think about crossing the first stent from the 3 segment to PL ( ostium of PD seems normal), and the 2nd stent not to cover the proximal segment, where CAG did not show servere lesion?
  • Jong-Young Lee 2011-12-19 Dr.che jingjin, Based on the IVUS findings, the optimal landing site and lesion length were decided which showed sometime different findings of angiogram. We deployed stent from distal optimal lesion to near the ostimal part of RCA by IVUS guidance. On the IVUS examination, there was also diffuse plaque burden in the 3 segment of PL branch, but the vessel size was too small and difficult to place the stent.
  • Jong-Young Lee 2011-12-19 Dr. Zening Jin and Joao Alexandre Farjalla, The decision to try PCI for a CTO (versus continued medical therapy or surgical revascularization) requires an individualized risk-benefit analysis encompassing clinical, angiographic, and technical considerations. There is still clinical uncertainties regarding which patients benefit from CTO revascularization. There has been no confirmatory answer based on randomized trial. The patient was too young patient who was eager to open the occluded artery.
  • Ricardo Quizhpe 2011-12-27 Congratulations Dr. Etsuo Tsuchikane, it seems like CTOs could be easy to do when we appreciate your work, but we need to learn more from technique and materials. I would say the proximal segment of RCA does not look like severe diseased, on the contrary of the origin and proximal PL branch. Also, I would never ask for CT angiography if I had a normal treadmill test.

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