Anterograde Approach for mid LAD CTO Lesion

- Operator : Seung-Whan Lee

Anterograde Approach for mid LAD CTO Lesion

- Operator: Seung-Hwan Lee, MD

Case Presentation

A 74 year-old man was referred for CTO intervention. He had suffered for effort chest pain about 6 month. The coronary angiogram showed totally occluded lesion at mid LAD and proximal LCX. His coronary risk factors were hypertension and hyperlipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=63%) without regional wall motion abnormality.

Baseline Coronary Angiography

The left coronary angiogram showed diffuse stenosis of whole LAD and total occlusion at mLAD with grade 2 collateral flow from PDA and bridging collateral flow of own proximal vessel. Total occlusion of pLCX was observed with grade 2 collateral flow from RV and PL branch of RCA ( Movie 1, Movie 2, Movie 3, Movie 4). The right coronary artery showed tubular lesion at mRCA with 50% of stenosis and another tubular lesion at dRCA with 90% of stenosis ( Movie 5).

Procedural Steps

A 7F sheath was inserted through right femoral artery, and the right coronary artery was engaged with a 7 Fr JL4 SH guiding catheter. 0.014-inch 180cm Sion blue wire was inserted into the RCA. Predilatation was performed with TREK 2.5 x 15mm balloon at mRCA and dRCA. Two Xience Xpedition 4.0 X 18 mm and 3.5 x 18 stents were successfully deployed at mRCA and dRCA respectively (Figure 1, Figure 2, Movie 6). After right coronary intervention, the left coronary artery was engaged with a 7 Fr XB 3.5 guiding catheter. We tried antegrade approach at mLAD by using a 0.014 inch Fielder XT wire with Finecross 0.014-inch 1.8 Fr 130cm microcatheter (Figure 3). While TRECK 2.5 x 15mm balloon was used for anchoring, and then we exchange the wire for 0.014-inch 190cm Gaia second. Predilatation was performed with Maverick 1.2 x 15mm balloon at mLAD (Movie 6). 0.014-inch 180cm Sion blue wire was positioned again. Xience Xpedition 3.5 x 23, 3.0 x 28 and 2.5 x 38 stents were successfully deployed at proximal to distal LAD (Figure 4, Figure 5, Figure 6). The following coronary angiogram showed well expanded stents at pm LAD with good distal run-off flow without any complication ( Movie 7, Movie 8).