Looks easy, but failed antegrade approach, finally retrograde approach was successful

- Operator : Etsuo Tsuchikane

Looks easy, but failed antegrade approach, finally retrograde approach was successful
- Operator: Etsuo Tsuchikane, MD
Case Presentation

A 63 year-old man was admitted our hospital for effort-related chest pain. We planned PCI before 1Mo, but discovered apical mural thrombi by echocardiogram. So, we started coumadization and delayed PCI.

He had a history of dyslipidemia, and ex-smoking with 20 pack-years. Thallium SPECT showed fixed large sized severe decreased perfusion in LAD territory. The trans-thoracic echocardiography revealed RWMA in LAD territory with normal LV systolic function (EF=58%) and disappeared apical mural thrombi after oral anticoagulation for 1 month.

Baseline coronary angiography

The target lesion was a CTO lesion in the proximal LAD. The distal LAD was well filled through the rich collateral channels of right coronary artery via the septal perforators.( Movie 1) Also, some visible contrast filling, suspected as true channel, was also visible in angiogram.

Procedure

First, we tried to antegrade approach with IVUS-gruided using by an 8 Fr XB 3.5 guiding catheter and the combination of an Fielder XT 0.014 inch guide-wire and a Finecross¢ç 0.014 inch 1.8 Fr -130cm microcatheter. (Figure 1, Figure 2) But, after wire-crooss to the true lumen, so we used parallel wire technique but also, we failed.
So, we tried to retrograde approach by a 7 Fr AL1 guiding catheter engaged in the right coronary artery through the 8 Fr femoral sheath. Initially, Using a Corsair¢ç 0.014 inch 2.6 Fr -150 cm Coronary Micro-Guide catheter, 0.014 inch Fielder FC wire was tried into septal branch via PDA branch.( Movie 2, Movie 3) During negotiation, we used 0.014 inch -180 cm Fielder XT. The retrograde wire was successfully advanced into the proximal LAD, fortunately. But the Corsair catheter could not pass the total lesion. We performed several balloon dilatation with OTW Ryujin 1.25*10mm sized balloon. After then, wire was slightly advanced and we captured the retrograde wire by Amadeus 3.0*10 sized balloon inflation in LAD guiding catheter.( Movie 4) Thereafter RG3 0.014 inch -330cm retrograde wire was externalized into the LAD guiding catheter using Finecross¢ç 0.014 inch 1.8 Fr -150cm Coronary Micro-Guide catheter. Using externalized wire, we inflated at mLAD by IKAZUCHI 2.0*15mm sized balloon at mLAD.( Movie 5) After several predilation, the antegrade wire was successfully advanced. Consecutive two Cypher select stents (2.5*33mm + 3.0*18mm) were deployed.(Figure 3) The final angiogram showed successful results.

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