Antegrade Approach for Proximal LAD CTO Lesion

- Operator : Etsuo Tsuchikane

Antegrade Approach for Proximal LAD CTO Lesion
- Operator: Etsuo Tsuchikane, MD
Case Presentation
A 53 year-old gentleman was referred for CTO intervention. One month ago, he visited our hospital for general health check-up. He complained of mild effort chest pain. His coronary risk factors were ex-smoking, and hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal LV function without RWMA. TMT showed horizontal ST depression on V4-6 at stage IV. Thus, we performed coronary angiography.
Baseline coronary angiography
1. The left coronary angiogram showed total occlusion at pLAD ( Movie 1, Movie 2).
2. The right coronary angiogram showed diminutive RCA with severe ostial stenosis ( Movie 3). We did not perform any procedure at ostial lesion because RCA is diminutive artery.
Left coronary artery was cannulated with a 7 Fr JL4 SH guiding catheter through right femoral approach. Initially, we tried antegrade approach at pLAD by using a 0.014 inch Fielder XT wire with Corsair 0.014 inch 2.6 Fr 150cm microcatheter. After negotiation, we succeeded in the engagement of wire into dLAD with Fielder XT 0.014 inch - 180 cm wire (Figure 1). Predilatation was performed with Maverick 1.5 x 15mm balloon at pmLAD (Figure 2). And then we changed Fielder XT wire to Sion blue 0.014 inch - 180cm into dLAD. Additional predilatation was performed with Maverick 2.5 x 20mm balloon at pmLAD (Figure 3). PROMUS Element stent 2.5 x 38mm and 4.0 x 38mm were implanted from distal LAD to distal LM (Figure 4, Figure 5). Adjunctive post-stenting balloon dilatation was done using a Quantum 3.5 x 15mm at LM to pLAD (Figure 6). Final angiogram showed that the procedure was successful ( Movie 4, Movie 5).

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