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  3. Case 10: RCA CTO (Antegrade Approach)

Case 10: RCA CTO (Antegrade Approach)

Case Presentation

  • A 62-year-old man presented with angina chest pain for a few days. Stress MPI showed moderate infero-lateral and apical ischemia.
  • LHC showed 3V CAD (calcified long CTO of mid RCA with bridging collaterals and collaterals from LAD/LCx, 95% proximal LAD, and 90% prox LCx). Syntax score 28 and LVEF 60%.
  • After Heart team discussion, patient opted for mutivessels staged PCI. He underwent successful DES PCI of pLCA and pLCx.
  • Medical History: HTN, HLD, NIDDM, FH+
  • Medications: ASA 81mg, Ticagrelor 90mg, Metoprolol XL 50mg, Atorvastatin 40 mg, fenofibrate 145 mg, Isosorbide Mononitrate 60mg, Metformin XL 1G, Empagliflozin 10mg

Angiogram

Description and Planning

PCI Strategy

  • CTO length ~ 20 mm, taper proximal cap
  • Bridging Collaterals ++
  • 6F IM guide catheter
  • AWE (Fielder/Caravel microcatheter > Gaia 3 > Confianza Pro)
  • If the antegrade failed, would consider a retrograde approach

STEPS

  • Since there was a small branch near the proximal cap, Fielder went to the branch during wire advancement.
  • AWE done using Gaia 3 which inadvertently went to acute marginal branch.
  • Then, Confianza 9 with Micro14 catheter was changed.
  • Since the guide catheter didn’t provide enough support, decided to exchange to AL 0.75 guide catheter.

AWE (Fielder > Gaia)

STEPS

  • The Confianza 9 was successfully negotiated to the distal RCA.
  • Since we couldn’t advance the microcatheter, planned to use balloon trapping technique to remove the microcatheter.

STEPS

  • For 6F guide catheter, we used 2.5 balloon(14 atm) to trap the wire at distal end and removed the microcatheter.

Wiring And Balloon Trapping Technique

STEPS

  • After removal of microcatheter, we used a guide catheter extension (Guidezilla in this case).
  • First, semicompliant balloon 1.2/6 mm was used, followed by NC 2.0/20 balloon dilatation.
  • One DES (Xience 3/38) was placed in RCA with an excellent result.

    The case can be reviewed at https://ccclivecases.org/july-2018-ccc-live-case

Final Angiogram

Learning Points

  • Pre-procedural planning is vital in CTO intervention along with planned AWE. Confianza Pro 9 crossed the CTO segment in this case.
  • If Gaia wire goes into subintimal space, we would strongly suggest to pull back and re-enter from a different entry point using a different wire. Here, we used Confianza wire.
  • If a microcatheter could not advance after wire crossed, consider to use balloon trapping technique to remove the microcatheter, followed by a serial balloon dilatation (starting from 1.0 > 1.2 > 1.5 > 2.0 mm).

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)              
681215202530
MINI TREK (CTO INDICATED)1.271.2
1.561.5
2.172✓*✓*
TREK2.372.25
2.672.5
2.912.75
3.113
3.53.25
3.73.5
3.943.75
4.324
4.864.5
5.365
*Only available as RX, not as OTW. Other sizes available in both versions.
Retrieved on April 07 2022 from Abbott product ordering information. Please look at the company's files for the latest available data on device configurations and avilability in your area.

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