Retrograde Approach for mid LAD CTO Lesion

- Operator : Young-Hak Kim

Retrograde Approach for mid LAD CTO Lesion

- Operator: Young-Hak Kim, MD

Case Presentation

A 58 year-old gentleman was referred for CTO intervention. He didn`t have distinctive symptom. But, abnormal results were shown in the exercise test and coronary CT angiography. His coronary risk factors were diabetes, hyperlipidemia, and smoking. The physical examination was unremarkable. The ECG and cardiac enzymes were normal The echocardiography showed normal left ventricular function (EF=64%) without regional wall motion abnormality.

Baseline Coronary Angiography

The left coronary angiogram showed total occlusion at dLAD, grade 3 collateral flow from RCA, and significant stenosis of mLAD and subtotal occlusion of diagonal branch ( Movie 1, Movie 2). The right coronary artery showed normal angiography and collateral flow to LAD ( Movie 3).

Procedure

The left coronary artery was engaged with 8 Fr JL4 guiding catheter and right coronary artery was positioned with 7 Fr JR guiding catheter through the bi-femoral approach, respectively. We tried anterograde approach at pLAD by using several 0.014 inch guide wire (Sion, Fielder XT, Fielder XTR, in serial) with Finecross micro-catheter, a Fielder XT guide wire passed into diagonal branch but a Fielder XTR guide wire entered false lumen at mLAD and could not proceed more (Figure 1, Figure 2). Therefore, We changed our plan to access retrograde approach. We tried a 0.014 inch Fielder XTR and a Sion Black wire with Corsair 0.014 inch 2.6 Fr 150 cm micro-catheter, but we failed to advance the wire into the proximal part. After several attempts of retrograde approach, we succeeded to pass wire into pLAD by using 0.014 inch Conquest pro wire with Corsair 2.5 Fr 150 cm micro-catheter (Figure 3, Figure 4, Movie 4). Using 0.010 inch guide wire RG3 330, we made a loop for retrograde wire externalization. Then BMW (power turn) 0.014 inch 300cm wire was inserted into the LAD (Figure 5). Predilatation was performed with Maverick 2.5 x 15mm and Lacrosse 2.0 x 15mm. Xience Xpedition 2.5 x 38mm was implanted at mdLAD and Xience Xpedition 3.5 x 38mm was implanted at pmLAD. Two stents were overlapped (Figure 6, Figure 7). Thereafter, post-stenting ballooning was performed by using Empira NC 3.5 x 15mm. The following coronary angiogram showed well expanded stents at pdLAD with good distal run-off flow ( Movie 5, Movie 6).