Chronic Total Occlusion; Side Branch IVUS-Guided CTO Intervention

- Operator : Shigeru Saito

Chronic Total Occlusion; Side Branch IVUS-Guided CTO Intervention

- Operator: Shigeru Saito, MD

Clinical Presentation

A 55 year-old man had old MI that occurred in 2001 and recently presented effort related chest pain for 3 months. But PCI was failed in other hospital because of failure of guidewire passage. So, he was referred to our hospital. Coronary risk factors were smoking. Initial cardiac enzyme levels showed normal range. His baseline ECG showed sinus bradycardia. Echocardiographc finding showed reduced global left ventricular systolic function (ejection fraction = 49%) and akinesia of mid anteroseptal wall.

Baseline Coronary Angiography

Coronary angiogram showed a total occlusion involving mid LAD with TIMI G0 flow and collateral flow grade II from RCA. (Figure 1 and Figure 2)

Procedure

RCA was engaged with 6F JR4 guiding catheter and left coronary artery was engaged with 8F XB 3.5 guiding catheter. At first, a 0.014¡± Finecross microcatheter with Runthrough-hypercoat guidewire (Terumo, Japan) was introduced into the left ventricular septal branch through the RCA (Figure 3), but it failed to pass through the septal artery to LAD. Subsequently a Fielder FC guidewire (Asahi Intecc, Japan) and a Miracle 3 guidewire (Neo¡¯s, Asahi, Japan) with Finecross microcatheter was advanced to mid LAD lesion retrogradely but all guidewire failed to pass the total segment retrogradely (Figure 4, Figure 5).
Alternative antergrade approach was attempted. IVUS was performed to identify true LAD luminal direction with a Runthrough guidewire (Terumo, Japan) indwelling from proximal LAD to diagonal branch. Then, Miracle 12 guidewire (Neo¡¯s, Asahi, Japan) and a Conquest pro 12 GW (Neo¡¯s, Asahi, Japan) were tried to penetrate mid LAD, so-called ¡®two wires system¡¯ (Figure 6). After successful penetration of Conquest pro 12 GW, Tornus microcatheter was used to cross the lesion, and Conquest pro 12 GW was exchanged to Runthrough guidewire. Predilation of mid LAD was performed with a Aqua 2.5 ¡¿ 15 mm balloon by 8 atm (2.5 mm) and Ryujin 3.0 ¡¿ 20 mm by 10 atms (3.18 mm) (Figure 7). After predilation, a 3.0 ¡¿ 24 mm Endeavor stent at mid LAD by 14 atm and a 4.0 ¡¿ 24 mm Endeavor stent was positioned at proximal LAD and deployed by 14 atm (Figure 8, Figure 9). Final angiogram demonstrated well-expanded stents with minimal residual stenosis and TIMI 3 flow (Figure 10).

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