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Anterograde Approach for proximal RCA CTO Lesion
- Operator: Seung-Whan Lee, MD
Case Presentation
A 67 year-old man was referred for CTO intervention. He had suffered effort chest pain for 4 years. The coronary angiogram showed totally occluded lesion at proximal-RCA. He had no coronary risk factor except for 75 pack-years of smoking. The physical examination was normal. The baseline ECG showed Q waves in lead II, III, aVF and cardiac enzymes were unremarkable. Thallium SPECT showed partially reversible large sized perfusion defects at RCA territory. And also there was focal akinesia at RCA territory with preserved LV systolic function on echocardiography.
Baseline Coronary Angiography
  1. The left coronary angiogram showed mild diffuse stenosis with ruptured plaque from LM to pLAD with 10.2mm2 of MLA on the IVUS. And there was a grade 2 collateral flow from LCX to rPDA ( Movie 1, Movie 2).
  2. The right coronary artery showed total occlusion at pRCA but, owing to the grade 3 bridging collateral flow from RCA cornus branch, TIMI flow 2 was obtained ( Movie 3).
Procedural Steps
As the proximal stump was visible, we planned to undergo antegrade approach. A 7F sheath was inserted through right femoral artery, and the right coronary artery was engaged with a 7 Fr AL1 SH guiding catheter. 0.014-inch 1.8 Fr 180cm FINECROSS micro-guide catheter with NEO’s(Fielder XT) 0.014-inch 190cm wire was inserted into the RCA. Luckily, wire tip penetrated the proximal cap smoothly, and reached to the distal cap safely. FINECROSS was delivered and Fielder XT was exchanged into BMW 0.014-inch 300cm. Predilatation was performed with Maverick 1.5 x 20mm balloon and BH PLUS 2.5 x 20 balloon. Xience Xpedition 3.5 x 33 mm was successfully deployed at pRCA (Figure 1, Figure 2, Figure 3). The following coronary angiogram showed well expanded stents at pRCA with good distal run-off flow without any complication ( Movie 4).
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