Retrograde Approach for Distal RCA CTO Lesion through the Thread-like Septal Branch

- Operator : Etsuo Tsuchikane

Retrograde Approach for Distal RCA CTO Lesion through the Thread-like Septal Branch
- Operator: Etsuo Tsuchikane, MD
Case Presentation
A 62-year-old gentleman presented with abnormal exercise treadmill test and thallium SPECT. His coronary risk factors were hypertension, dyslipidemia and smoking. The physical examination was unremarkable. The ECG and cardiac enzymes were normal. The transthoracic echocardiography showed near normal LV systolic function (EF=50%) with regional wall motion abnormality of RCA territory. The exercise treadmill test was positive at stage 3 and the thallium SPECT showed partially reversible large sized perfusion defect at RCA territory.
Baseline Coronary Angiography
1. Left coronary angiogram showed mild to intermediate coronary artery disease of LAD and LCX. It also showed collateral flow from septal branches of LAD to RCA ( Movie 1, Movie 2, Movie 3).
2. Right coronary angiogram showed total occlusion at mid to distal RCA ( Movie 4).
Procedure
Right coronary artery was cannulated with a 7 Fr AL1 SH guiding catheter and left coronary artery was positioned with a 7 Fr EBU 3.5 SH guiding catheter through the bi-femoral approach. After engaging guiding catheter into coronary arteries, we checked image by simultaneous injection of right and left coronaries. It showed additionally dissected proximal RCA induced by catheter besides baseline angiographic findings ( Movie 5). Initially, we inserted a 0.014 inch Sion Blue wire into RCA using a Cosair¢ç 135cm microcather for marking (Figure 1). And then, we tried to reach the CTO lesion several times through several septal braches using some wires and a Cosair¢ç 150cm microcatheter (Figure 2, Figure 3, Figure 4). After several trials, we barely found the optimal septal brach (Figure 5). We tried to pass the CTO lesion with a 0.014 inch Sion wire using a Cosair¢ç 150cm microcatheter through PDA branch but it went wrong with us (Figure 6). So, we tried it with a 0.014 inch Gaia Second wire using a Cosair¢ç 150cm microcathter through PL branch and we could successfully advance to mid RCA. A retrograde wire was exchanged for a 0.010 inch RG3 330cm wire. And then we performed several balloon dilatations at proximal to distal RCA using a TREK balloon 2.5x15mm and a Sprinter legend balloon 2.0x15mm. After predilatations, we deployed a Xience Prime stent 3.0x38mm at proximal RCA and additional ballooning was done using a Fortis balloon 3.5x13mm (Figure 7). A subsequent coronary angiogram showed mid RCA collapsed ( Movie 6). We inferred that this phenomenon could be developed due to hematoma extension associated with proximal dissection previously seen on IVUS ( Movie 7). So we deployed a Xience Prime stent 2.5x38mm at distal RCA before mid RCA stenting because of interrupting extension of hematoma to distal part (Figure 8). Finally, we deployed a Xience Prime stent 3.0x38mm at mid RCA overlapping other stents (Figure 9). Thereafter, we performed additional ballooning with stent balloon 3.0x38mm. The final angiogram showed successful revascularization at RCA CTO lesion ( Movie 8).

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