Recanalization of Chronic Totally Occluded Left Anterior Descending Artery Supported by 64-Channel Coronary MDCT

- Operator :

Recanalization of Chronic Totally Occluded Left Anterior Descending Artery Supported by 64-Channel Coronary MDCT
- Operator: Jae-Sik Jang, MD
Clinical Information

- Relevant clinical history and physical exam:
A 71-year old women was admitted due to effort chest pain. Her coronary risk factors were hypertension and diabetes.

- Relevant test results prior to catheterization:
There were T wave inversion at precordial leads on electrocardiogram. Echocardiography showed concentric LVH without regional wall motion abnormalities. Coronary MDCT revealed near total occlusion of LAD from proximal to mid segment with diffuse fibrous plaques and multifocal calcified plaques.

- Relevant catheterization findings:
1. Right coronary angiogram showed minimal narrowing at mid RCA. Collateral flow to LAD was not good to visualize the occluded LAD. (Figure 1, Figure 2, Figure 3)
2. Left coronary angiogram revealed total occlusion of proximal LAD with TIMI 1 flow and there was no visible stump. (Figure 4, Figure 5, Figure 6, Figure 7, Figure 8)

Interventional Management

Procedural step:
LAD was engaged with 7F XB 3.75 guiding catheter. Although the exact entry point of occluded LAD could not be defined definitely by angiogram, coronary MDCT findings showed that occluded segment was just adjacent to big diagonal bifurcation point. (Figure 9) At first, antegrade wiring was attempted with a 0.014 inch Runthrough PTCA wire (Terumo, Japan) and it did not penetrate proximal cap. (Figure 10) Another 0.014 inch PTCA wire (Miracle 3, Terumo, Japan) was attempted, but failed too. (Figure 11) After several attempts, 0.014 inch Miracle 6 PTCA wire (Terumo, Japan) was advanced forward and began to penetrate toward the correct direction. (Figure 12, Figure 13, Figure 14, Figure 15, Figure 16, Figure 17) Then, predilation of proximal to mid LAD was achieved with a Ryujin 1.25 × 15 mm balloon (Figure 18) by 8 atm (1.3 mm), a Ryujin 2.0 × 15 mm balloon (Figure 19) by 12 atm (2.17 mm), and a Ryujin 2.5 × 20 mm balloon (Figure 20) by 8 atm (2.58 mm) sequentially. After predilation, a 3.0 X 30 mm Endeavor stent (Figure 21) was positioned at proximal to mid LAD and deployed by 14 atm (3.18 mm) and a 3.0 × 24 mm Endeavor stent (Figure 22) at mid LAD by 14 atm (3.18 mm). Additional ballooning of proximal stent was done with a 3.0 × 24 mm stent balloon (Figure 23) at 18 atm (3.34 mm). Final angiogram showed well-expanded stents with no residual narrowing. (Figure 24, Figure 25)

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