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Case 16: PCI of Distal RCA CTO by Retrograde Recanalization using LAD-Septal Collaterals

Case Presentation

  • A 48-year-old man presented with new onset of crescendo angina (CCS class III) and stress MPI showed moderate size inferior wall ischemia.
  • Prior History: Hypertension, Hyperlipidemia
  • Medications: ASA 81mg, Metoprolol XL 100mg, Ranolazine 1000mg, ISMN 30mg, Simvastatin 40mg, Enalapril 5mg
  • Cardiac catheterization revealed 1V CAD; total occlusion of distal RCA filling via bridge and septal retrograde collaterals.
  • LVEF 60% and SYNTAX score 12.
  • Planned to do recanalization of distal RCA CTO using retrograde approach via LAD-septal collaterals.

Angiogram

PCI Strategy

  • CTO length ~20 mm with good collaterals from LAD-septal.
  • Initial approach: Retrograde, Dual injection
  • Initial wire would be Fielder with Corsair microcatheter
  • Caution: Stent in LAD
  • Wire escalation with retrograde approach to enter the distal lumen
  • If Retrograde approach failed, would try antegrade approach

Case Planning

STEPS

  • First, we started with Fielder and Corsair microcatheter to wire LAD septal to RCA.
  • Once we reached to rPDA, changed to a stiffer wire to go through the distal cap of CTO.
  • Wire escalation was done accordingly from MiracleBros 6 > Confianza 9 > Progress 200T > Astato XS 20.
  • Finally, Astato XS 20 (Tip load of 20g) went through distal CTO cap and wire externalization using ViperWire was performed.
  • FineCross microcatheter and a workhorse wire (Runthrough 300) was advanced into the RCA, followed by removal of ViperWire and Corsair.

Retrograde Wiring

Wire Externalization and Exchange to Workhorse Wire

STEPS

  • After Runthrough wire was advanced into the RCA, predilatation with NC 2.5/30mm was done, followed by three DES stents placement (4/16, 3/38, and 2.75/28 mm).

Case Overview

Learning Points

  • Presence of bifurcation near the distal cap (CTO) makes the retrograde approach challenging to wire into the vessel (like in this case) and will require a stiffer wire with higher tip load to go through the distal cap.
  • Like AWE, the operator should have a wire escalation plan in retrograde approach.
  • We used Fielder > MiracleBros 6 > Confianza 9 > Progress 200T > Astato XS 20.
  • Be careful not to push hard if there is any resistance while advancing Corsair through LAD stent strut; as it could disrupt the LAD stent architecture.

Left Main DK Crush Video ID