Retrograde Approach for Proximal RCA CTO Lesion through the Septal Branch

- Operator : Seung-Whan Lee

Retrograde Approach for Proximal RCA CTO Lesion through the Septal Branch

- Operator: Seung-Whan Lee, MD

Case Presentation

A 47 years-old gentleman was admitted for abnormal findings for routine physical examination. His coronary risk factors were hypertension and dyslipidemia. He visited primary clinic and mild left ventricular dysfunction was confirmed. In this time, total occlusion of proximal RCA was found in coronary CT angiography. As akinesia of inferior wall was found in echocardiography, we decided to revascularize his coronary artery.

Baseline Coronary Angiogram

Left coronary angiogram showed normal coronary arteries of LAD and LCX. It also showed collateral flow from septal branches of LAD and LCX to RCA ( Movie 1). The right coronary angiogram showed total occlusion of RCA from its proximal portion. ( Movie 2).

Procedure

Right coronary artery was engaged with a 7 Fr AR 2 guiding catheter and left coronary artery was positioned with a 7 Fr AL 2 guiding catheter through the bi-femoral approach. At first, we tried anterograde approach using Sion Blue and Fielder XT-R with Finecross 130cm catheter, but it was not successful (Figure 1). After that, we tried retrograde approach using Sion blue, Sion black, Fielder XT, Fielder XT-A, Ultimate 3, Gaia 2 wire with Cosair® 150cm microcatheter through septal branches (Figure 2). After several trials, we penetrated the proximal cap with Fielder XT wire ( Movie 3). After advancement of Corsair® microcatheter into the right guiding catheter, a retrograde wire was exchanged for a 0.010 inch RG3 wire. And then we performed several balloon dilatations at proximal to distal RCA using a Sprinter legend 1.5x15mm and Maverick balloon 1.5x25mm (Figure 3). After predilatations, we deployed three Promus Premier Stents (4.0x16mm, 3.5x38mm and 2.75x38mm) sequentially, the final angiogram showed successful revascularization at RCA CTO lesion ( Movie 4).