Slides

Retrograde Approach for Proximal RCA ISR CTO Lesion Through the Thread-like Septal Branch

- Operator : Seung-Whan Lee

Retrograde Approach for Proximal RCA ISR CTO Lesion Through the Thread-like Septal Branch
- Operator: Seung-Whan Lee, MD
Case Presentation
A 57-year-old gentleman presented with effort chest pain. Fifteen years ago, he underwent PCI at proximal LAD (NIR 2.5×25mm) and proximal RCA (J&J 4.0×17mm) in our hospital. His coronary risk factors were hypertension and ex-smoker. The physical examination was unremarkable. The ECG and cardiac enzymes were normal. The transthoracic echocardiography showed moderately decreased LV systolic function (EF=40%) with regional wall motion abnormality of LAD and RCA territory. The exercise treadmill test was negative.
Baseline Coronary Angiography
  1. Left coronary angiogram showed discrete moderate ISR at mid LAD and tubular moderate stenosis at distal LCX. It also showed collateral flow from septal branches of LAD to RCA ( Movie 1, Movie 2).
  2. Right coronary angiogram showed ISR with total occlusion at proximal RCA ( Movie 3).
Procedure
A 7F sheath was inserted through right femoral artery, and the left coronary artery was engaged with a 7F JL5 catheter. 0.014-inch NEO’s (Soft) wire with a FINECROSS 0.014 inch 1.8Fr-130cm microcatheter was inserted into the LCX. The guidewire was changed to BMW(powerturn) 0.014 inch-300cm. After that, 0.014-inch NEO’s (Soft) wire was inserted into the LAD (Figure 1). Distal LCX was predilated with 3.0 x 15mm Pantera LEO balloon. We dilated mid LAD using 3.0 x 15mm Pantera LEO balloon for anchoring. A XIENCE Xpedition 3.5 x 38 mm stent was successfully deployed at dLCX (Figure 2). After that, we predilated with a Flextome Cutting balloon 3.0 x 10mm and dilated with a DEB, SeQuent Please, 3.0 x 26mm at mid LAD ISR lesion (Figure 3). 014-inch NEO’s (SION) wire with a Corsair 0.014 inch 2.6Fr-150cm microcatheter was inserted from LAD to RCA by retrograde approach (Figure 4). And guidewire was changed to Fielder XT R 0.014 inch-180cm. Right coronary artery was positioned with 7Fr JR4 guiding by left femoral artery. The guidewire was inserted from the left guiding catheter to the right guiding catheter and it formed a wire loop (retrograde wire externalization) ( Movie 4). From the guidewire tip outside the right sheath, predilatation with Lacrosse 2.0 x 15mm, Pantera LEO 3.0 x 15mm and Flextome Cutting balloon 3.0 x 10mm was performed proximal RCA. We dilatated mid RCA with a DEB, SeQuent Please, 3.0 x 30mm (Figure 5). Final angiogram showed that the procedure was successful ( Movie 5).

Comments

  • Imad Sheiban 2014-10-02 Angiogram for RCA was not selective . It seems that RCA was not ostial CTO. In that case , being ISR total occlusion , there is a big chance for a successful antegrade recanalization ( less costly and shorter procedure ).

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