LAD CTO Lesion

- Operator : Satoru Otsuji

LAD CTO Lesion
- Operator: Satoru Otsuji, MD
Case Presentation
A 66-year-old man was admitted through the emergency department for sudden resting chest pain. While awaiting coronary angiography, he developed NSTEMI. His coronary risk factor was dyslipidemia and smoking. He underwent coronary angiography on the day following the NSTEMI. The coronary angiogram showed subtotal occlusion at 1st diagonal branch and CTO lesion at the pLAD. We performed PCI at diagonal lesion as culprit but wiring attempt at the pLAD CTO lesion was failed at that time. The echocardiography showed akinesia of LV apex with normal LV systolic function (EF=56%). We decided to revascularize his LAD.
Baseline Coronary Angiography
  1. Left coronary angiogram showed total occlusion of the pLAD and previous stent in diagonal branch ( Movie 1, Movie 2).
  2. The right coronary artery showed mild stenosis at the proximal and distal RCA and collateral flow between LAD and PDA via septal branches ( Movie 1, Movie 2).
Procedure
Both femoral arteries were assessed with 7F sheaths. The left coronary artery was engaged with a 7 Fr EBU 3.75 guiding catheter and right coronary artery was engaged with a 7 Fr JR 4.0 guiding catheter. We tried the anterograde approach using Sion blue, fielder XT-R, Gaia 1 with Corsair 150cm micro-catheter, but it was not successful ( Movie 3). After that, we tried retrograde approach using Sion blue, SUOH wire with Caravel 150cm micro-catheter and using SUOH, Ultimate 3, miracle 3 with FINECROSS micro-catheter ( Movie 4, Movie 5). After careful subintimal tracking of the retrograde guidewire directed to the tip of antegrade guidewire, the subintimal space was dilated with PCI balloons (IKAZUCHI zero 1.0 x 6 mm, Tazuna 2.0 x 15 mm in antegrade direction ( Movie 6, Movie 7). Then retrograde wire was linked up with the antegrade wire in proximal true lumen, and the retrograde wire was externalized into the LAD guiding catheter ( Movie 8). It was followed by the usual PCI procedure. Predilatations were performed with Tazuna 2.0 x 15 mm balloon at the pmLAD. After predilatation, we deployed two Ultimaster stents (2.5 x 38mm and 3.5 x 24mm) sequentially ( Movie 9, Movie 10). Post dilatation of the proximal to middle LAD was performed with NC Rovl 2.75 x 15 mm and Tazuna 2.0 x 15 mm. The final angiogram showed successful revascularization at the LAD CTO lesion ( Movie 11).

Leave a comment

Sign in to leave a comment.