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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.

Angiogram

PCI Strategy

  • 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

Case Planning

STEPS

  • 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.

Wiring Technique (Fielder FC > MiracleBro 6)

Wiring Technique (MicracleBro 6 > Confianza 9)

Confianza 9 > Fielder

STEPS

  • 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.

Balloon Trapping Technique

Final Angiogram

Case Overview

Learning Points

  • 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.

Left Main DK Crush Video ID