Case

A Case of Chronic CTO of RCA: Anterograde Approach

- Operator : Etsuo Tsuchikane

A Case of Chronic CTO of RCA: Anterograde Approach
- Operator: Etsuo Tsuchikane, MD
Clinical presentation

A 67 year-old man was admitted to evaluate and manage the coronary vessels. He has a history of stent implantation in proximal LCX with BMS(GFS 3.5X18mm) at Dec.1998 and proximal to mid LAD with Cypher 3.0X33, 3.0X28mm at Feb.2004. At that time, there was also total occlusion of RCA. However, the trying of PCI was failed. After then, he had been visiting our OPD without chest pain. However, the chest pain was developed nowadays. So we decided to check the coronary vessel state with thallium scan. That scan showed reversible large sized moderately decreased perfusion in apical-mid anterior, apical septal and mid-basal anteroseptal wall (Figure 1). Because of the finding of thallium scan , we suspected ISR of deployed stent or new developed coronary artery stenosis. So we took a coronary angiogram for this patient. Coronary angiogram showed patent previous stent and new developed diffuse 80-90% stenosis in distal LCX (Figure 2). After coronary angiogram, Two stents with Cypher 3.0X33mm, 3.5X18mm were implanted (Figure 3). And then, staged PCI about total occluded RCA lesion was decided.

Baseline coronary angiogram

1. Right coronary angiogram showed TIMI 0 flow from proximal RCA with bridging collateral (Figure 4).
2. Left coronary angiogram showed patent stent in the LAD and LCX. And collateral branch from LAD to RCA via septal branch was shown (Figure 5)

Procedure

Right coronary ostium was cannulated with an 7 Fr Judkin 4.0 guiding catheter. Initially, by using a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter, the Fielder XT 0.014 inch guide-wire was advanced (Figure 6). The first guidewire passage failed and entered into the subintima (Figure 7). Therefore, a second Miracle 3 guidewire was tried again to the distal part of the total occlusion (Figure 8). However, the Miracle 3 guidewire could not cross into the distal true channel (Figure 9), so it was changed to a Miracle 12 guidewire (Figure 10). Then, the Miracle 12 guidewire succeeded to cross total occlusion (Figure 11). Pre-dilation was performed at proximal to middle RCA with 1.5 X 15mm Ryujin balloon (Figure 12). And, further dilation was done at proximal to mid RCA with a 2.5 X 15mm Sprinter balloon (Figure 13). After this further dilation, a 3.0 X 33mm Cypher stent (by 16atm, 3.21mm) was implanted in the proximal RCA (Figure 14). Then, additional post-dilation was performed with a stent balloon (Figure 15). The angiogram after stenting showed residual lesion at mid to distal RCA (Figure 16). For the residual mid to distal RCA lesion, pre-dilation was performed with 2.5X15 mm Sprinter balloon (Figure 17). After this pre-dilation, a additional 2.75X33mm Cypher stent (by 16atm, 2.96mm) was implanted in the mid to distal RCA by overlapping with previous stent (Figure 18). And then, post stenting balloon was performed with a 3.5 X 20mm Dura star balloon in the proximal to distal RCA (Figure 19). After post ballooning, IVUS evaluation revealed under-expansion of stent at proximal edge. So, further dilation with Ultra-soft 5.0X20mm(by 10 atm, 5.23mm) was performed (Figure 20). Final angiogram showed successful revascularization at RCA CTO lesion (Figure 21).

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