Anterograde Approach for LAD CTO Lesion

- Operator : Seung-Whan Lee

Anterograde Approach for LAD CTO Lesion

- Operator: Seung-Whan Lee, MD

Case Presentation

A 58 year-old male patient was admitted for effort chest pain for 2 months ago. His coronary risk factor was ex-smoking and hypertension. He had previous history of STEMI and underwent PCI at RCA other hospital 3 months ago. There was CTO lesion also at proximal LAD but PCI was failed at that time. He had continued on medical treatment since then. In this time, the left ventricular systolic function was near normal without regional wall motion abnormalities, we decided to re-vascularize his coronary artery.

Baseline Coronary Angiogram

Left and right coronary angiogram showed mild coronary artery disease of LAD and LCX, and previous stent in the LCX-OM branch were found to be patent. It also showed collateral flow from epicardial channel of RCA to LAD ( Movie 1). The right coronary angiogram showed previous stent of proximal RCA was found to be patent ( Movie 2).

Procedure

Right coronary artery was engaged with a 6 Fr AL 1 guiding catheter and left coronary artery was positioned with an 8 Fr JL 4 guiding catheter through the bi-femoral approach. We tried to pass the CTO lesion by anterograde approach using Gaia 2 wire with Crusade® 140cm microcatheter ( Movie 3). Lastly, we tried to pass the CTO lesion by anterograde approach with Gaia 2 wire. And then, we successfully pass wire into LAD CTO lesion ( Movie 4). After advancement of Corsair® microcatheter with LCX balloon backup, we performed several balloon dilatations at proximal to middle LAD using Lacrosse balloon 1.0 x 5 mm and Emergy 1.5 x 15 mm (Figure 1). After predilatations, we deployed two Xience Alpine stents (2.75x38mm and 3.5 x 33 mm, middle to proximal LAD, Figure 2, Figure 3) sequentially. The final angiogram showed successful revascularization at LAD CTO lesion ( Movie 5).