Slides

Retrograde approach "Reverse CART technique", mRCA CTO lesion

- Operator : Etsuo Tsuchikane

Retrograde approach "Reverse CART technique", mRCA CTO lesion
- Operator: Etsuo Tsuchikane, MD
Case Presentation
A 35 year-old man was admitted with efforting chest pain for three years. His coronary risk factors were hypertension, diabetes, hyperlipidemia, and current smoking. As a non-invasive function test, thallium SPECT was done and showed fixed large size perfusion defect of RCA territory. The trans-thoracic echocardiography showed normal LV systolic function without regional wall motion abnormality. Baseline coronary angiogram showed significant stenosis at proximal LAD and chronic total occlusion at middle RCA. Two weeks ago, we performed PCI at proximal LAD. And then we decided to perform PCI at middle RCA CTO.
Baseline Coronary Angiogram
1. A left coronary angiogram showed patent stent at proximal LAD and weak collateral flow from septal branch to PDA. ( Movie 1)
2. A right coronary angiogram showed chronic total occlusion at middle RCA with TIMI 0 flow ( Movie 2).
Procedure
Firstly, left coronary ostium was cannulated with an 7 Fr EBU 3.5 guiding catheter and right coronary ostium was positioned with 7 Fr AL1 diagnostic catheter. Initially, by using a PCI-guide wire; Sion blue 0.014 inch-180cm was passed through LAD to septal branch with Corsair 0.014 inch-150cm (Figure 1). After many attempt and change guidewire, we successfully advanced to PDA branch using Sion blue 0.014 inch 180cm with Corsair 0.014 inch 6Fr-150cm (Figure 2). And then, antegrade guidewire (Gaia second 0.014inch 190cm) with finecross 0.014 inch 1.8Fr-130cm could not be passed into true lumen of mRCA. Using CART technique, small balloon (Ryujin 2.0 * 20) was used in subintimal space creation in antegrade direction (Figure 3). After then, retrograde wire was externalized into RCA guiding catheter and Sion blue 0.014 inch - 180cm with Crusade 0.014 inch 2.9Fr was advanced to PL branch by antegrade approach (Figure 4). Muliple balloon predilation with Ryujin 2.0 * 20 was performed at dRCA to PDA branch and dRCA to PL branch. After predilatation, Promus Element 2.5 * 38 mm was implanted at distal RCA to PDA branch and re-wiring with Sion blue to PL branch. We performed kissing balloon angioplasty with Maverick 2.0 * 15 at distal RCA to PL branch and with Ryujin 2.0 * 20 at PDA branch (Figure 5). The RCA angiogram showed diffuse stenosis at middle to distal RCA ( Movie 3). Two Promus Element 3.5 * 38 was implanted at middle to distal RCA and proximal to middle RCA (Figure 6, Figure 7). The final angiogram showed well positioned and expanded stent with good distal run-off flow. ( Movie 4)

Comments

  • Abdulrahman Almoghairi 2013-11-29 the patient is young why not bioabsorbable Scaffolds the other thing why 7 fr guides , why not radial ?
  • Seung-Whan Lee 2013-12-02 thank you for your interest and question, in our country BVS is not available. 7 Fr guiding is our default guiding size. 6 Fr is sometimes difficullt to show the angiographic finding when multiple devices were used. if IVUS use is considered 8 Fr should be used. in addition, in our center femoral approach is also default approach for the stong back-up. We Know radial approach is relatively benefit to patients and minimize complication. but In CTO interevention, femoral approach is preferred in our center for strong-back-up support

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