Retrograde wire technique in the case of LADos CTO lesion intervention

- Operator : Seung-Whan Lee

Retrograde wire technique in the case of LADos CTO lesion intervention
- Operator: Seung-Whan Lee, MD
Case Presentation
A 56 year old man was admitted with stable angina pectoris. His coronary risk factor was hypertension and smoking. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=65%) without regional wall motion abnormality.
Baseline coronary angiography
The left coronary angiogram showed total occlusion at left anterior descending artery (LAD) os, and subtotal occlusion at distal left circumflex artery (LCX). ( Movie 1, Movie 2) The right coronary angiogram showed significant stenosis at distal right coronary artery. And distal LAD was well filled through the rich collateral channels of RCA via the septal perforators. ( Movie 3)
Procedure
A 7Fr AL1 ST guiding catheter was engaged in the right coronary artery, and an 8Fr XB3.5 guiding catheter was engaged in the left coronary artery through the bi-femoral approach. After the advancement of 0.014-inch Floppy guidewire into the LCX, intravascular ultrasound (IVUS) was performed to identify the exact position of CTO lesion of LADos. At first, by using the combination of a Fielder XT 0.014-inch 190cm guidewire and a Finecross 0.014-inch 1.8Fr 130cm microcatheter, the anterograde approach was attempted. However, the wire was gone to another side branch, so it was failed. Secondly, the retrograde approach was attempted. Fortunately, the relatively well-visible septal collateral channells from RCA to LAD was shown. By using the combination of a Fielder FC 0.014-inch 180cm guidewire and a Finecross 0.014-inch 1.8Fr 150cm microcatheter, the arterial lumen distal to the CTO lesion was successfully reached through the septal branch via the RCA. Retrograde wire crossing technique was attempted and succeeded. Retrograde Fielder FC wire was advanced somewhat easily. The retrograde wire was inserted into the left guiding catheter lumen, and then the channel catheter was inserted into the left guiding catheter. The 0.014-inch 300cm Fielder FC wire was inserted from right guiding catheter to the left guiding catheter and it formed a wire loop (retrograde wire externalization). From the guidewire tip outside the right sheath, predilation with the Amadeus 2.5 x 15mm balloon was performed. ( Movie 4) New Floppy 0.014-inch 180cm was inserted from the left guiding catheter and predilatation with the Amadeus 2.5 x 15mm balloon was performed. ( Movie 5)
By using the combination of a Miracle 6 0.014-inch -180cm guidewire and a Finecross 0.014-inch 1.8Fr -130cm microcatheter, the anterograde wire was inserted into the LCX. And then, Miracle 6 0.014-inch 180cm guidewire was exchanged by Floppy 0.014 inch -300cm wire. Predilatation using an Amadeus 2.5 x 15mm and an IKAZUCHI 1.5 x 15mm balloon were performed in the distal LCX. After IVUS examination, we deployed a Xience Prime Stent 2.5 x 38mm at the distal LCX with postdilatation using a SAPPHIRE NC 3.0 x 15mm. ( Movie 6)
Thereafter, predilatation using an Amadeus 2.5 x 15mm and a SAPPHIRE NC 3.0 x 15mm were sequentially performed in the mid to proximal LAD. ( Movie 7) After IVUS examination, we deployed a Xience Prime Stent 3.0 x 38mm at the mid LAD and Xience Prime Stent 4.0 x 38mm at the proximal LAD to distal LM with postdilatation using a SAPPHIRE NC 3.0 x 15mm and Fortis 4.0 x 13mm. Final angiogram showed well-expanded and well-positioned stents. ( Movie 8)

Comments

  • Dobrin Vassilev 2011-04-09 Very good case - congratulations! Why Miracle wire was needed to enter LCX?
  • Young-Hak Kim 2011-04-09 Filder FC could not pass the lesion so that a stiffer wire was used.
  • Jingjin Che 2011-04-12 very clear strategy and very good result!

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