Stump-less LAD CTO Lesion

- Operator : Seung-Whan Lee

Stump-less LAD CTO Lesion

- Operator: Seung-Whan Lee, MD

Case Presentation

A 52 year-old man was referred for CTO intervention. He had suffered for effort angina about 1 month. The coronary angiogram showed totally occluded lesion at proximal LAD and diffuse stenosis at mid RCA. His coronary risk factors were hyperlipidemia and history of ex-smoking. The physical examination was normal. The ECG revealed old septal infarction and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=59%) with akinesia of apical septum and mid anteroseptum.

Baseline Coronary Angiography

The left coronary angiogram showed total occlusion at proximal LAD ( Movie 1, Movie 2). The right coronary artery showed diffuse intermediate disease at mid RCA with grade 3 collateral flow to distal LAD & diagonal branch. FFR at mid RCA lesion was checked 0.75 after 140mcg/kg/min IV adenosine ( Movie 3, Movie 4).

Procedural Steps

An 8F sheath was inserted through right femoral artery and 7F sheath through left femoral artery. The left coronary artery was engaged with a 8 Fr JL 4.0 guiding catheter and right coronary artery was engaged with a 7 Fr JR 4.0 guiding catheter. We tried antegrade approach, firstly. A 0.014 inch 180cm Sion blue was placed in Ramus intermedius and a 0.014-inch 190cm Fielder XT wire supported by Finecross microcatheter was engaged for LAD (Figure 1). With IVUS guidance, LAD ostium was tracked and luckily passed by Ultimate 3 ( Movie 5). As the wire was placed in big diagonal branch ( Movie 6), wire was exchange into 0.014-inch 300cm BMW (Powerturn) and Ramus intermedius wire was removed. With Corsair support, Ultimate 3 was passed through LAD ( Movie 7) and exchanged into another 0.014-inch 300cm BMW (Powerturn). Predilatation was performed with Maverick 1.5 x 15mm and 2.5 x 15 mm balloon at proximal LAD, several times (Figure 2). After IVUS evaluation, XIENCE Xpedition 3.0 x 23 mm and 4.0 x 28 mm stents were successfully deployed at proximal LAD to LM (Figure 3). The following coronary angiogram showed well-expanded stents at pm LAD with good distal run-off flow without any complication except for competitive flow in big diagonal branch ( Movie 8, Movie 9). After left coronary intervention, 0.014-inch 180cm Sion blue wire was inserted into the RCA. Predilatation was performed with Tazuna 2.0 x 15mm balloon at mRCA, XIENCE Xpedition 4.0 X 38 mm stent was successfully deployed at mRCA respectively (Figure 4, Movie 10).