Retrograde & Anterograde Approach for midLAD CTO Lesion

- Operator : Toshiya Muramatsu

Retrograde & Anterograde Approach for midLAD CTO Lesion

- Operator: Toshiya Muramatsu, MD

Case Presentation

A 61 year-old man was referred for CTO intervention. He had suffered exertional shortness of breath for 2 month. The coronary angiogram showed totally occluded lesion at mLAD. He received CABG (LIMA to dLAD, SVG to OM2, SVG to dLCX) 2 years ago. His coronary risk factors were hypertension, diabetes, hyperlipidemia, and smoking. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. Thallium SPECT showed reversible large sized perfusion defects at LAD territory. The echocardiography showed normal left ventricular function (EF=63%) without regional wall motion abnormality.

Baseline Coronary Angiography

The left coronary angiogram showed total occlusion at mLAD, grade 2 collateral flow from OM, and significant stenosis of LIMA to LAD was seen ( Movie 1, Movie 2). The right coronary artery gives little collateral flow to LAD ( Movie 3).

Procedure

The Right coronary angiogram didn’t show collateral flow to distal LAD. So, we planned to check collateral flow by LIMA. Left coronary artery was cannulated with a 7 Fr Lt (EBU 3.5) SH guiding catheter and LIMA was positioned with 7 Fr LIMA SH guiding catheter through the bi-femoral approach, respectively. We tried retrograde approach at LIMA to LAD by using several 0.014 inch guide wire with Finecross 0.014 inch 1.8 Fr 130cm microcatheter, but the guidewire could not be passed into the lumen of LAD because of vessel angle tortousity. Therefore, We changed our plan to assess antergrade approach. (Figure 1, Figure 2). We tried antegrade approach by using a 0.014 inch Runthrough NS wire with Finecross 0.014 inch 2.9 Fr 140 cm microcatheter, but we failed to advance wire into distal part because plaque hardness. So we changed to Conquest pro 0.014 inch wire (more hard wire). We failed to advance wire in mLAD but succeeded advance of Conquest Pro in septal branch. After that, we tried antegrade approach by useing Fielder FC wire with Crusade 0.014 inch 140 cm microcatheter. and succeeded to pass wire into mLAD. Predilatation was performed with Lacrosses 2.5 x 15mm for anchoring at pLAD up to 6 atm and Emerge 2.0 x 15mm at mLAD up to 12 atm (Figure 3). We succeeded in the engagement of 0.014 inch Conquest Pro wire into pLAD to dLAD (Figure 4). Predilatation was performed with Emerge 2.0 x 15mm at mLAD up to 10 atm and Lacrosse 2.5 x 15mm at mLAD, mdLAD up to 10 atm. A 0.014 inch Runthrough NS wire 180cm was positioned at pLAD to dLAD (Figure 5). Predilatation was performed with Lacrosses 2.5 x 15mm at mdLAD and pmLAD up to 12 atm. Xience Xpedition 2.5 x 38mm was implanted at mdLAD. Xience Xpedition 2.75 x 38mm was implanted at mLAD. Xience Xpedition 3.0 x 33mm was implanted at pmLAD. (Figure 6, Figure 7, Figure 8). 3 stents were overlapped. The following coronary angiogram showed well expanded stents at pdLAD with good distal run-off flow without any complication ( Movie 4).