Retrograde Approach Using "Reverse CART technique" for Proximal RCA CTO lesion

- Operator : Etsuo Tsuchikane

Retrograde Approach Using "Reverse CART technique" for Proximal RCA CTO lesion
- Operator: Etsuo Tsuchikane, MD
Case Presentation
A 60-years-old male patient visited our hospital for effort-related chest pain. He was a current smoker who had smoked for 40 pack-years. He had diabetes and hyperlipidemia as another coronary risk factors. The transthoracic echocardiography showed akinesia at mid posterior wall with normal LV function (EF=58%). Thallium SPECT presented a reversible large sized moderate to severe perfusion defect in anteroseptal wall and partially reversible moderate defect in inferior wall. Initial coronary angiogram showed diffuse stenotic atheromatous lesion in mid LAD, chronic total occlusion of distal LCX, and chronic total occlusion of proximal RCA. The patient refused bypass surgery. So, we planned to perform two staged PCI for mid LAD and RCA CTO lesion, and treat medically for distal LCX lesion. At first, we performed stenting for mid LAD lesion successfully. In this time, we present 2nd stage PCI for RCA CTO lesion.
Baseline Coronary Angiography
1. Left coronary angiogram showed patent stent at mid LAD and total occlusion at distal LCX ( Movie 1).
2. Right coronary angiogram showed total occlusion at proximal RCA with collateral flows from septal channels ( Movie 2, Movie 3).
Procedure
Right coronary artery was cannulated with a 7 Fr AL1 SH guiding catheter and left coronary artery was positioned with 5 Fr JL 4 diagnostic catheter through the bi-femoral approach, respectively. Initially, we tried to insert a 0.014 inch Conqeust Pro guide wire with anterograde approach using a Corsair¢ç 150cm microcatheter, but the wire entered a false lumen ( Movie 4). And then we changed right fermoral 5 Fr sheath to 7 Fr sheath and engaged left coronary artery with 7 Fr EBU 3.5 SH guiding catheter. Next, a 0.014 inch Filder XT guidewire with a Corsair¢ç 150cm microcatheter was tried via LAD collateral channel by retrograde approach ( Movie 5, Movie 6). Thereafter, a 0.014 inch Hi-Torque progress guide wire was advanced into proximal RCA by retrograde approach. However, the wire was not easily advanced into a 7 Fr AL1 SH guiding catheter. For better externalization, we changed right guiding catheter from a 7 Fr AL1 SH to JR 4 7 Fr SH. After changing a guiding catheter, we could pass. And then, the retrograde wire was exchanged into a 0.014 inch 300cm RG3 wire. And then we performed several balloon dilatations at proximal RCA with Sequent 2.5x15mm balloon, Sprinter 2.5x15mm balloon (Figure 1). After predilatations, we deployed 2 consecutive stents with overlapping at RCA (Resolute integrity stent 3.0x38 mm and 3.5x12 mm) (Figure 2, Figure 3). The final angiogram showed successful revasculariztion at RCA CTO lesion ( Movie 7, Movie 8).

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