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Retrograde Approach for Proximal RCA Chronic Total Occlusion
- Operator: Seung-Whan Lee, MD
Case Presentation
A 63-year-old man admitted to our hospital for chronic total occlusion. He underwent PCI at the left man (LM) to mid LAD (Xience 3.5×28mm, 3.0×23mm) about 7 years ago for stable angina. His coronary risk factors were hyperlipidemia and an ex-smoker with 40 pack-year. The physical examination and ECG was unremarkable. The treadmill test was positive on stage 3. The transthoracic echocardiography showed normal LV systolic function (EF=63%) without regional wall motion abnormality.
Baseline Coronary Angiography
  1. Left coronary angiogram showed patent previous stents at LM to mid LAD and tight stenosis at ostium of LCX. It showed well developed epicardial collateral flow from septal and marginal branch of LAD and LCX to RCA ( Movie 1, Movie 2, Movie 3).
  2. Right coronary angiogram showed total occlusion at proximal RCA ( Movie 4).
Procedure
A 7F sheath was inserted through both femoral artery. Right coronary artery engaged with a 7F AL1 catheter and left coronary artery was engaged with a 7F XB 3.5 catheter. At first, we tried anterograde approach using 0.014-inch 180cm Fielder XT-R, Gaia 2 and Conquest Pro 12 with Finecross microcatheter (Figure 1). And then, we tried to make use of parallel wire technique using 0.014-inch 180cm Runthrough NS with Corsair microcatheter (Figure 2), but those were not successful. After that, we tried retrograde approach using 0.014-inch 180cm Sion, Sion Black, Runthrough NS, Fielder XT-R, SuHO with Corsair support through septal branches (Figure 3), but from the distal septal branch, wires could not advance. And then, we changed plan to retrograde approach through branch LCX, ostium of LCX dilated with 2.0 x 15 mm and 2.5 x 15 mm Tazuna balloon, and 0.014-inch 180cm SuHO with Finecross microcatheter advanced through collateral branch of LCX (Figure 4). After several trials, SuHo wire penetrated the distal cap of RCA CTO lesion (Figure 5). The retrograde wire passed into the right guiding catheter and Finecross catheter was advanced. Wire was exchanged into RG3 and formed a closed loop (Figure 6). Predilation was performed with 2.5 x 15 mm Tazuna balloon from proximal to mid RCA (Figure 7). The IVUS finding revealed the passage was true lumen. A XIENCE Alpine 3.0 x 38 mm and 3.5 x 38 mm stents was successfully deployed at mid to proximal RCA successfully (Figure 8). Final angiogram showed that the procedure was successful ( Movie 5).
Jae Hong Park2016-09-25
Sincerely your practical case is good. At first Diagonal branch is spaced good at proximal part, but not good at distal one. You would better have chosen LCX branch which might be good for retrograde approach route from the first. would you do final kissing ballooning after POBA for LVX Os? And I think the antegrade wire left to catch the approximate pathway.Thanks for sharing your good case through on line web site.
Se Hun Kang2016-09-25
Thank you for your comment. As you said the diagonal collateral branch was bad at distal part, so initial approach was not successful. Consequently, approach though diagonal branch was failure, but if possible, diagonal branch would be better choice for retrograde approach. As the ostium of LCX was treated with small sized balloon, final kissing balloon was not performed.
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