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Case 14: RCA CTO via Antegrade Approach

Case Presentation

  • A 36-year-old presented with new onset angina chest pain.
  • A stress MPI revealed moderate anterior, septal, apical, and inferior walls ischemia with TID.
  • Medical history: HLD, NIDDM
  • Medications: ASA 81mg, Ticagrelor 90mg BID, Metoprolol XL 50mg, ISMN 60mg, Glipizide 10mg, Rosuvastatin 10mg
  • Cardiac catheterization revealed 3 V CAD; 100% mid RCA, 95% prox LAD, 80% OM2 and 90% LCx-LPL with LVEF 50% and Syntax score of 26.
  • Heart team discussion was done for revascularization options and patient chose multivessels PCI approach.
  • Planned for staged PCI of CTO RCA via antegrade approach using CenterCross device or via retrograde septal collaterals.

Angiogram

PCI Strategy

  • CTO lesion length ~10 mm
  • Collaterals ++
  • Antegrade approach with wire escalation
  • Dual injection
  • May use a support catheter (i.e. CenterCross) along with microcatheter
  • If antegrade approach fails, would attempt retrograde approach
  • Planned AWE (Fielder/Micro14 > Miraclebros > Hornet 14 or Confianza 12)

Case Planning

Devices Discussion

CenterCross Device

STEPS

  • With the support of 7F guide catheter, we positioned CenterCross catheter along with the Runthrough wire and Micro14 microcatheter.
  • Then AWE performed by using Fielder, then changed to Miraclebros 6.
  • The wire was not able to advance, then exchanged to Hornet 14 (Tip diameter 0.008, with tip load of 14 g) without success.
  • Confianza 12 was used to cross the lesion. However, it was not successful.
  • Then we exchanged Micro14 to FineCross and tried with Gaia 3 wire, which was subsequently escalated to Progress 200T (0.009” tip with tip load of 13.3g).
  • Progress 200T finally passed the distal cap of CTO, followed by serial balloon dilatation and two DES were placed to mid and distal RCA with an excellent result.

CTO Crossing

Final Angiogram

Learning Points

  • The use of different type of wires in the antegrade wire escalation is very important and the operator should have the pre-planned strategy for AWE.
  • The operator successfully crossed CTO with Pilot 200T which has hydrophilic tapering tip from 0.014” to 0.009”, intermediate polymer sleeve with distal 3cm uncoated.
  • The CenterCross device is useful to keep the wire in the center of the lumen during AWE while providing an additional support.

Left Main DK Crush Video ID