Retrograde Approach For pLAD ISR CTO

- Operator : Jae-Hwan Lee

Retrograde Approach For pLAD ISR CTO
- Operator: Jae-Hwan Lee, MD
Case Presentation
A 68-year-old gentleman was admitted for elective PCI. Seven years ago, he underwent PCI at LM to proximal LAD in other hospital. One month ago, he had experienced STEMI, and was treated with primary PCI at proximal LCX. At that time, ISR with total occlusion at proximal LAD was also noted. His coronary risk factors were hypertension, diabetes mellitus, hyperlipidemia and ex-smoking. The echocardiography showed normal LV systolic function without RWMA (EF=56%). TMT was positive at stage 2 and thallium scan showed reversible large sized perfusion defect at LAD territory.
Baseline coronary angiography
The left coronary angiogram showed subtotal occlusion with thrombus at pLCX and in-stent total occlusion at pLAD ( Movie 1) and the right coronary angiogram was normal.
Procedure
Left coronary artery was cannulated with a 7 Fr AL1 ST guiding catheter and right coronary artery was positioned with 8 Fr EBU 3.5 SH guiding catheter through the bi-femoral approach, respectively. Initially, by using the Corsair¢ç 0.014 inch 2.6 Fr 150cm microcatheter, NEO¡¯s Ultimate bros¢ç 0.014 inch 180cm guidewire was tried into LAD. But, we failed, guidewire was changed to FINECROSS¢ç 0.014 inch 1.8 Fr 150cm, NEO¡¯s miracle 3 0.014 inch 175 cm was tried into LAD. After crossing the LAD (Figure 1), it was successfully negotiated with distal LAD ISR lesion, and microcatheter was changed to Crusade¢ç. Secondary, Corsair¢ç 0.014 inch 2.6 Fr 150cm microcatheter, NEO¡¯s Miracle 3¢ç 0.014 inch 175cm guidewire was approached to retrograde pathway to LAD. We failed several times for guidewire to pass into the septal branch. Finally, 0.014-inch SION guidewire was successfully advanced into septal branch by retrograde approach(Figure 2). We performed several balloon dilatation with Sphrinter legend 1.25*14mm sized balloon on pmLAD(Figure 3). Thereafter SION 0.014 inch -175cm retrograde wire was advanced into LAD guiding catheter (Figure 4). After advancing SION across the occlusion site, the retrograde wire was exchanged for a 0.014 inch 330cm Extension wire (Figure 5). And then we performed several balloon dilatation with IKAZUCHI 2.5x20mm sized balloon (Figure 6). After several predilation, we sequentially deployed a XIENCE PRIME LL stent 3.0 x 38mm at the pLAD (Figure 7). Then, final kissing balloon dilation was performed with a Quantum 4.0 x 15mm in pmLAD to LM and a Quantum 3.0 x 15mm in pLCX to LM. (Figure 8). Final angiogram showed successful stent expansion without periprocedural complications ( Movie 2).

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