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

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.

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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