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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.

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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