Case 17: PCI of CTO RCA via Retrograde Approach

Case Presentation

A 57-year-old man presented with new onset CCS Class IV angina. He was diagnosed with 2 V CAD and had PCI of LCx. But he had 2nd failed attempt at antegrade recanalization of CTO RCA.
He continued to have Class II angina and a stress MPI revealed moderate inferior wall ischemia.
Medical History: Hypertension, Hyperlipidemia
Medications: ASA 81mg, Prasugrel 5mg, Lisinopril 10mg, Rosuvastatin 20mg, Nebivolol 5mg, ISMN 60mg
Coronary angiogram revealed 2 V CAD (CTO of RCA and subtotal occlusion of LCx-LPL branch).
LVEF 60% and SYNTAX score 24.
Planned to do PCI of CTO RCA via retrograde approach due to failed antegrade approach.

2 sequential CTO lesions with prior failed antegrade approach
Collaterals ++ from LAD septal to RCA.
Planned to do Retrograde approach
Dual injection
Initial wire choice: Fielder/Fielder FC with Corsair Pro (150cm)
Consider wire escalation as needed (Fielder/Fielder FC > MiracleBros 6 > Confianza Pro)
Wire externalization with balloon trapping
Exchange with FineCross and Runthrough 300cm

We used Fielder and Corsair to negotiate from LAD septal branch to RCA
Then exchange to Fielder FC as a wire escalation strategy
Subsequently, we had done wire escalation to go through distal CTO; Fielder FC > MiracleBros 6 > Confianza Pro.
However, Confianza 9 went to subintimal plane and difficulty in redirecting to the true lumen.
We finally used Fielder which went into the true lumen and antegrade guide catheter.

Once the wire reached to RCA guide catheter, we used a balloon (2.5/15) for wire trapping, then advanced Corsair into the RCA guide catheter.
We can use long wire (330-350 cm) for externalization. Here, we used ViperWire.
Then, advanced antegrade FineCross/Runthrough wire to perform PCI, followed by removal of ViperWire and Corsair.
Two DES (3.25/38 and 3.5/38) were placed with good angiographic result.

In Retrograde approach via LAD-septal, selection of an appropriate septal branch is the most important step and if needed, consider to take the selective angiogram of a septal branch via a microcatheter.
A trans-septal wiring can be done by using a hydrophilic wire with microcatheter (i.e. Fielder/Corsair) and other dedicated retrograde wires [Fielder XT-R, Sion Black (Asahi), Suoh 03 (Asahi)] can also be used.
Although distal CTO cap is presumptively easier to go through, wire escalation strategy is necessary in some cases. We used Fielder FC, Whisper, Gaia 3, MiracleBros 6, and Confianza 9.
It is challenging to negotiate a stiff retrograde wire into the guide catheter or true lumen if there are multiple small dissection planes.
We would strongly recommend to use a soft, hydrophilic wire such as Fielder, Whisper ES to negotiate back into the true lumen.