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Anterograde and Retrograde Approach for LAD CTO Lesion
- Operator: Seung-Whan Lee, MD
Case Presentation
A 62 year-old male patient was admitted for chest discomfort for several months. His coronary risk factor was smoking and hyperlipidemia. He had previous history of NSTEMI and underwent percutaneous coronary intervention (PCI) at RCA and LCX from other hospital 3 months ago. There was chronic total occlusion (CTO) lesion also at proximal LAD but PCI was failed at that time. He had continued on medical treatment. Echocardiography showed multiple regional wall motion abnormalities with left ventricular systolic function. We decided to revascularize his LAD.
Baseline Coronary Angiography
  1. Left and right coronary angiogram showed mild coronary artery disease of pLAD and LCX, chronic total occlusion of mLAD and previous stent in the LCX-OM branch were patent. It also showed collateral flow from epicardial channel of RCA to LAD ( Movie 1).
  2. The right coronary angiogram showed previous stent of proximal RCA was found to be patent ( Movie 2).
Procedure
Right coronary artery was engaged with a 7 Fr AL 1 guiding catheter and left coronary artery was positioned with a 7 Fr XB 3.5 guiding catheter through the bi-femoral approach. We tried to pass the CTO lesion by anterograde approach using Fielder XT, Gaia2 wires with Corsair® 135cm microcatheter. After several trials, anterograde approach was not successful ( Movie 3). We tried retrograde approach to pass the proximal LAD-CTO lesion through epicardial collateral channel with a 0.014 inch Sion BLUE wire and Corsair® 150cm, but we failed to penetrated the distal cap of LAD( Movie 4). Lastly, we tried to pass the CTO lesion by anterograde approach with hard wire with Conquest Pro 12. And then, we successfully pass wire into LAD CTO lesion ( Movie 5). After advancement of Corsair® microcatheter, we performed several balloon dilatations at proximal to middle LAD using Lacrosse balloon 1.0x5mm and IKAZUCHI 2.0x20mm (Figure 1). After predilatations, we deployed two Synergy stents (2.5 x 38mm and 3.5 x 38mm, Figure 2, Figure 3) sequentially. The final angiogram showed successful revascularization at LAD CTO lesion ( Movie 6).

Appendix
IVUS image of post-ballooning ( Movie 7) and post stent implantation ( Movie 8).
Sumiya Tserendavaa2017-01-20
May I need to see IVUS after pass wire into LAD CTO lesion?
Se Hun Kang2017-01-20
Thank you for your comment. You meant that you want to see the IVUS image after wire passage before stent implantation. We will upload the IVUS image soon.
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