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Retrograde Approach via the Epicardial Collateral Branch for a RCA CTO Lesion
- Operator: Seung-Whan Lee, MD
Case Presentation
A 64-year-old male was admitted for chest discomfort for several months. His coronary risk factor was hypertension, hyperlipidemia. He has a previous history of stable angina and underwent percutaneous coronary intervention (PCI) at the pmLAD and mRCA in other hospital 5 years ago. Chronic total occlusion (CTO) lesion at the distal part of the mRCA stent was found 5 months ago, accordingly, medical treatment rather than PCI was initiated at first. However, his chest discomfort has not improved and the thallium-SPECT showed reversible perfusion defect at the RCA territory. We decided to revascularize dRCA CTO lesion.
Baseline Coronary Angiogram
  1. The left coronary angiogram showed normal feature and patent pmLAD stent and epicardial collateral flow from LCX to PL and PDA ( Movie 1).
  2. The right coronary angiogram showed total obstruction at the distal part of the distal RCA stent ( Movie 2).
Procedure
The right coronary artery was engaged with a 7 Fr AL 1 guiding catheter and the 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 Sion, Fielder XT, Gaia1 wires with Corsair® 135cm microcatheter. After several trials, we passed the wire through the CTO lesion but could not locate the wire inside the lumen of distal RCA and PL branch ( Movie 3). We tried the retrograde approach to reach normal vessel branches of PL and PDA behind the CTO lesion through epicardial collateral channel from the proximal LCX with ASAHI SUOH wire with Caravel® 150cm ( Movie 4), and finally we successfully passed the CTO lesion with Sion black by retrograde approach ( Movie 5). After advancement of Corsair® microcatheter, we replaced the wire with RG3 and performed several balloon dilatations at PL to distal RCA using IKAZUCHI 2.5x15mm ( Movie 6). After predilatations, we deployed two Synergy stents (2.75 x 38mm and 3.0 x 20mm, Movie 7, Movie 8) sequentially at the distal RCA and PL overlapping the previous mid RCA stent. And we deployed one Synergy stent (3.5X32mm) at the proximal RCA overlapping previous mid RCA stent ( Movie 9) and performed postdilatations with NC TREK 3.5X20mm. The previous mid RCA stent was treated with DEB (Pantera Lux 3.5X30mm) ( Movie 10). The final angiogram showed successful revascularization at the RCA CTO lesion ( Movie 11).
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