Retrograde Approach for Proximal LAD CTO

- Operator : Seung-Whan Lee

Retrograde Approach for Proximal LAD CTO
- Operator: Seung-Whan Lee, MD
Case Presentation
A 58-year-old female presented with a history of exertional shortness of breath over the last 1 month. The echocardiography showed LAD & LCX territory RWMA with mild LV dysfunction (EF=48%). The thallium scan showed partially reversible large sized perfusion defect at LAD & LCX territory. Her coronary risk factors were hypertension and hyperlipidemia.
Baseline Coronary Angiography
  1. A left coronary angiogram showed total occlusion at pLAD and diminutive pLCX with significant stenosis ( Movie 1, Movie 2).
  2. A right coronary angiogram showed multiple stenosis at dRCA to PL and PDA. And distal LAD was well filled through the rich collateral channels of RCA via the septal perforators ( Movie 3, Movie 4).
Procedure
Right coronary artery was cannulated with a 7 Fr JR4 SH guiding catheter and left coronary artery was positioned with 7 Fr XB 3.5 guiding catheter through the bi-femoral approach, respectively. Initially, by using the combination of XT-A 0.014 inch 175cm guidewire and a Corsair¢ç 0.014 inch 2.6 Fr 150cm microcatheter, the arterial lumen distal to the CTO lesion was successfully reached through the septal branch via the RCA (Figure 1, Figure 2). The retrograde wire was changed into a Conquest Pro 12, 0.014 inch 180cm guidewire. The antegrade wire (BMW 0.014 inch 190 cm guidewire) was located in proximal LAD ostium stump for indicator (Figure 3). The retrograde wire (Conquest Pro 12) was advanced into left main lumen. After advancing Corsair system across the occlusion site, the regtrograde wire was exchanged for a RG-3 0.010 inch 330cm wire ( Movie 5). The retrograde wire was advanced into the antegrade guiding catheter and externalized. We performed several balloon dilatation with Maverick 1.2 x 15 mm balloon and Trek 2.5 x 15 mm balloon over the externalized RG-3 wire (Figure 4). The BMW 0.014 inch 190 cm guidewire was advanced into distal LAD by antegrade approach, and we performed several predilation at proximal to distal LAD with Empira NC 2.5 x 15 mm balloon. The sequential three stent (XIENCE PRIME stents 2.5 x 38 mm, 3.0 x 23 mm, and 3.5 x 28 mm) were deployed at left main to distal LAD (Figure 5, Figure 6, Figure 7). And post dilatation was performed on left main to distal LAD stent with Quantum 3.0 x 15 mm balloon. The final angiogram showed well positioned and expanded stents with good distal run-off flow without any complication ( Movie 6, Movie 7).

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