Chronic CTO of Mid-LAD Intervention in Separate Ostium in Left Coronary System

- Operator : Etsuo Tsuchikane

Chronic CTO of Mid-LAD Intervention in Separate Ostium in Left Coronary System
- Operator: Etsuo Tsuchikane. MD
Clinical Information
66 year-old man was admitted to evaluate and manage the coronary vessels. He has a history of smoking with 30 pack-years. He did not have an other coronary risk factors. He suffered from dyspnea on exertion since last year. There were no significant abnormalities in pulmonary system. But there was diffuse, near total occlusion of proximal to mid LAD in coronary MDCT. There was Q-wave in V1~3 leads. The trans-echocardiography showed akinesia of mid anteroseptum and LV apex with mild LV systolic dysfunction (EF=48%). So he admitted to recanalize the occluded coronary artery lesion.
Baseline coronary angiogram
1. Left coronary angiogram showed TIMI 0 flow at proximal portion of LAD with collateral from RCA (Figure 1). And the left main is very short with separate LAD and LCX ostium (movie 1, IVUS figure1)
2. Right coronary angiogram showed collateral flow to LAD via epicardial collaterals. (Figure 2)
Procedure
Firstly, left coronary ostium was cannulated with an 8 Fr XB 4.0 guiding catheter and right coronary ostium was with 5 Fr AR II diagnostic catheter. Initially, by using a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter, Miracle 3.0g 0.014 inch guide-wire was advanced and then using microcather, the small contrast was injected into Left coronary artery (Figure 3). The exact stump point of LAD was achieved with IVUS-guidance (Figure 4). The guidewire (Fielder FC 0.014 inch 180 cm) was advanced into septal collateral to LAD, but the guidewire could not be passed into true lumen of LAD due to dissection. (Figure 5, Figure 6) Secondly, we changed diagnostic catheter into 7 Fr AL 1 guiding catheter at RCA. A Fielder FC 0.014 inch 180cm guidewire with a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter was approached to retrograde pathway to LAD. (Figure 7) With due to very severe tortuosity, the wire was changed to Whisper 0.014 inch 190cm and Corsair 0.014 inch 150cm (septal dilator) was used. (Figure 8) but retrograde approach was failed due to severe tortuosity and guiding catheter instability. Finally, we adopted LCX retrograde approach via Right femoral sheath. (Figure 9) A Fielder FC 0.014 inch 180cm guidewire with a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter was approached to retrograde septal pathway to LAD. The Fielder XT 0.014 inch 180cm guidewire was successfully advanced to mid-to distal LAD. (Figure 10) And then, Corsair 0.014 inch 150cm (septal dilator) was used in microchannel dilatation. (Figure 11) We cannulated with another 7 Fr JL 4.0 guiding catheter in left anterior descending coronary artery via left femoral sheath. This two guiding catheter engagement could be done because of big, separate ostium. A miracle 6.0g guidewire with a Finecross® 0.014 inch 1.8 Fr -130cm microcatheter was advanced into antegrade approach. (Figure 12) Using CART technique, small balloon (Ryujin 1.25 * 15 & 2.5 * 15) were used in subintimal space creation in antegrade direction. (Figure 13) After then, retrograde wire was externalized into LAD guiding cathter. (Figure 14) After then, multiple balloon dilatation, was performed and Fielder FC guidewire was inserted into LAD by antegrade approach. (Figure 15) The LAD angiogram showed diffuse stenosis in proximal to distal LAD. (Figure 16) The consecutive three Endeavor-resolute (3.0*30mm+3.0*30mm + 3.5*24mm) was deployed. (Figure 17, Figure 18, Figure 19) Final angiogram showed well positioned and expanded stent with good distal run-off flow. (Figure 20, Figure 21)

Comments

  • dswho@mac.com 2009-04-04 Dear Etsuo Can you elaborate the details in the sentence between Fig 14 and 15 ? Did you use antegrade balloon? What balloon? How did you trap the externalized retrograde wire? David
  • Fadili 2009-04-27 Dear Etsuo Tsuchikane, congratulations, excellent acute result. Fadil
  • Etsuo Tsuchikane 2009-05-22 Dear David, I used antegrade balloon (Ryujin 1.25 * 15 & 2.5 * 15) to create a subintimal space, so that was "Reverse CART technique". The retrogarde wire was advanced into the antegrade GC and then was trapped there by balloon (Ryujin 2.5 * 15) at 10 ATM, so that a Corsair could be followed into the GC. Then the wire was changed to a 300cm Fielder FC wire. Predilatation was performed using this reversed 300c wire and then a microcatheter was advanced to change the wire to another antegrade wire. You can see a tip of microcatheter in Fig 15. This strategy using Corsair/reverse CART/300cmWire is now our standard technique in retrograde approach. Etsuo

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