Ping-pong Technique for CTO

- Operator : Seung-Whan Lee

Ping-pong Technique for CTO
- Operator: Seung-Whan Lee, MD
Case Presentation
A 52 years old male patient was hospitalized for chest pain via emergency department. His coronary arterial disease risk factor was diabetes, dyslipidemia, and smoking. His physical exam was normal. The electrocardiogram and CK-MB were unremarkable, but Troponin-I was elevated upto 2.410 ng/mL. Echocardiography revealed akinesia of left ventricular basal inferoseptal and mid-anteroseptal wall with near normal left ventricular systolic function.
Baseline Coronary Angiogram
  1. Left and coronary angiogram showed total occlusion at mid LAD ( Movie 1) with collateral flow from diagonal branch ( Movie 2).
  2. The right coronary angiogram showed subtotal stenosis at proximal RCA and diffuse significant stenosis through mid to distal RCA ( Movie 3).
Procedure
7 Fr sheaths were inserted thorough bilateral femoral arteries. PCI for RCA was done with 7 Fr AR guiding catheter, 0.014-inch 180cm Sion wire, Tazuna 2.5 x 15 mm pre-balloon, two Synergy 3.5 x 24mm stents, and Raiden III 3.5 x 15 mm post-balloon.

Left coronary artery was engaged with a 7 Fr XB guiding catheter. Ante-grade wiring to LAD was failed with 0.014-inch 180cm Sion, 0.014-inch 190cm Fielder XT, and 0.014-inch 190cm Gaia 2 with the micro-guide catheter Corsair 2.6Fr. Retro-grade wiring for LAD through diagonal collateral was successful with 0.014 inch 180cm Sion black wire with Caravel micro-guide catheter 2.6 Fr ( Movie 4, Movie 5). Additional guiding catheter (JL 7Fr) was engaged to left coronary artery, and extension wire 0.014 inch 165cm was used for retrograde wiring into additional JL guiding catheter ( Movie 6). Pre-dilatation was done with 2.5 x 15 mm Tazuna balloon through Sion black and extension wire ( Movie 7). And then, 0.014 inch 180cm Sion wire was inserted into LAD antegradely ( Movie 8). Synergy 2.5 x 38mm ( Movie 9) and 4.0 x 32mm ( Movie 10) was implanted at LAD. After stenting, we performed additional balloon angioplasty with Raiden III 3.5 x 15 mm ( Movie 11). Final angiogram ( Movie 12) and IVUS ( Movie 13) showed that the procedure was successful.

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