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).
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.
