Case 17: PCI of CTO RCA via Retrograde Approach
- 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.
Wiring Technique (Fielder FC > MiracleBro 6)
Wiring Technique (MicracleBro 6 > Confianza 9)
Confianza 9 > Fielder
- 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
The case can be reviewed at https://ccclivecases.org/june-2015-ccc-live-case
- 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.