Retrograde & Antergrade Approach for Proximal RCA CTO Lesion Through the Thread-like Septal Branch

- Operator : Yasushi Asakura

Retrograde & Antergrade Approach for Proximal RCA CTO Lesion Through the Thread-like Septal Branch

- Operator: Yasushi Asakura, MD

Case Presentation

A 69-year-old gentleman presented with effort chest pain for several months. His coronary risk factors were dyslipidemia and current smoker. The physical examination and ECG was unremarkable. The transthoracic echocardiography showed normal LV systolic function (EF=68%) without regional wall motion abnormality. The exercise treadmill test was positive on stage 3 with CTO of RCA and LCx. For stable angina symptom, he underwent CAG three weeks ago, and diagnosed as 3VD. At the same time, he underwent PCI at proximal LAD (Two Xience Xpedition 3.5×15mm, 3.25×38mm) and Ramus intermedius (RI, Xience Xpedition 2.75×23mm). For the LCx CTO lesion, we planned medical treatment and for the proximal RCA CTO lesion, staged PCI was planned.

Baseline Coronary Angiography

Left coronary angiogram showed patent previous stents at proximal to mid LAD and RI. It showed well developed epicardial collateral flow from LAD to RV branch ( Movie 1). Right coronary angiogram showed total occlusion at proximal RCA ( Movie 2).

Procedure

Firstly, we planned for antegrade approach. A 8F sheath was inserted through both femoral artery. Right coronary artery engaged with a 8F JL4 catheter and left coronary artery was engaged with a 8F XB3.5 catheter. RCA CTO lesion was tried using 0.014-inch NEO’s (Fielder XT-R) wire with Corsair support. Because of tight stenosis on osRCA, proximal the the CTO lesion, advancing the wire was not easy at all. Therefore, we changed our plan to assess retrograde approach. We tried retrograde approach by using a 0.014-inch Sion wire, via septal channel. After wiring at septal artery, the proximal LAD stent strut was dilated using 1.5 x 15mm Ikazuchi balloon for the passage of Corsair. We changed the wire into 0.014-inch Gaia 2nd and successfully advanced through collateral channel ( Movie 3). After that, we tried antegrade approach by using 0.014-inch Gaia 2nd wire with Corsair and advanced wire into RCA (Figure 1). By rotational angiogram, we can adjust the direction of the wire ( Movie 4). And finally, the antegrade and the retrograde wire were crossed and reverse CART was done (Figure 2). The retrograde wire passed into the right guiding catheter and Corsair was advanced (Figure 3). Wire was exchanged into RG3 and formed a closed loop. Predilation was performed with 2.5 x 15mm Ikazuchi balloon and 3.0 x 20mm TREK balloon from proximal to mid RCA. The IVUS finding revealed the passage was in the true lumen. A XIENCE Xpedition 3.0 x 38 mm and 4.0 x 33 mm stents was successfully deployed at mid to proximal RCA successfully. Final angiogram showed that the procedure was successful and also there was no complications on LCA ( Movie 5, Movie 6).