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Case 12: CTO Ostial LAD (Retrograde / Antegrade)

Case Presentation

  • A 52-year-old man presented with shortness of breath and chest pain. Diagnosed with acute systolic heart failure, type 2 MI, and required invasive ventilation.
  • He was medically optimized and TTE showed EF 30%.
  • LHC showed 1 V CAD: flush long 100% occlusion of ostial LAD with excellent collaterals from RCA, J-CTO score 3, and syntax score of 20.
  • Stress MPI revealed large area of severe anterior wall predominant ischemia with partial scarring.
  • Medical History: Hypertension, Hyperlipidemia, Smoker (50 pack yrs), COPD, OSA, Morbid obesity (BMI 36.7)
  • He continued to have symptoms while on maximum medical therapy and then decided to perform PCI of LAD CTO.

Angiogram

PCI Strategy

  • Lesion length: > 20 mm
  • Dual injection (6F VL for left system, 6F IM for right system)
  • Collateral + (Epicardial and faint septal [Rt to left] )
  • Retrograde approach first (Corsair 150 cm with Fielder/Fielder FC)
  • If retrograde fails, will attempt antegrade approach
  • Antegrade approach with AWE ( Fielder/FineCross > Miracle 6 or Gaia 3 > Confianza Pro)

Case Planning

Wiring STEPS

  • Started the case with retrograde approach with Fielder/Corsair.
  • But the wire didn’t through the septal as the collaterals are small size and not have direct communication.
  • After we had tried couple of times, we switched to antegrade approach with Fielder/FineCross.
  • AWE was done (Fielder > Gaia3).
  • Gaia 3 went to subintimal inadvertently, then changed to > Confianza 12.

Retrograde Approach

AWE (Fielder > Gaia 3)

Gaia 3 > Confianza 12

  • After the Confianza wire crossed, it was exchanged to a workhorse wire, followed by serial balloon dilatation.
  • Two DES (3.0/38 and 3.5/38) were placed in proximal and mid LAD with good result.

Learning Points

  • Gaia series are made of tapered tip, composite core design compared to traditional design (core to tip), which enhance excellent 1:1 torque control.
  • Composite core (Dual Core and Dual coil) is made of multiple wire components to enhance durability and torque transmission.
  • However, if Gaia inadvertently enters into subintimal, one should consider MiracleBros/Confianza 12 to redirect into the lumen.
  • MiracleBros wire’s tip can be shaped into a desired configuration, compared to Gaia family (came in as 1mm pre-shaped tip) and better in navigating through angulated side branch and aneurysm lesions.

Left Main DK Crush Video ID