Case 18: PCI of CTO RCA using Retrograde Recanalization
Case Presentation
- A 62-year-old man presented with new onset crescendo angina and positive stress echo for infero-lateral ischemia.
- Coronary angiogram showed 3V CAD. CABG was recommended but patient declined.
- He underwent Resolute Integrity (3.5/30mm) DES PCI of distal LCx.
- Prior History: Hypertension, NIDDM, Family history +
- Medications: Aspirin 81mg, Prasugrel 5mg, Atenolol 50mg, Amlodipine 5mg, Metformin XR 1000mg, Glimepiride 2mg, Omeprazole 20mg
- Coronary angiogram revealed 3 V CAD (60% prox LAD, 80% distal LCx and 100% distal RCA) and normal LV function; SYNTAX score 22.
- Planned for PCI of distal RCA CTO using retrograde recanalization.
PCI Strategy
- CTO Length ~ 20-25 mm, Multiple bridging collaterals, Septal collateral to RCA ++
- Retrograde approach: Dual injection, 6F guide catheter
- Initial wire: Fielder/Corsair 150 cm
- Wire escalation as needed
- Externalization and antegrade wiring with FineCross and Runthrough
- If retrograde fails, consider to go antegrade approach
Case Analysis
How to Approach Retrograde PCI
Three Challenges in Retrograde Approach
STEPS
- We used Fielder and Corsair 150 cm to negotiate through LAD septal branches without any difficulty.
- Then changed to MiracleBros 6 which went through the distal CTO cap.
- A stiff wire (i.e. MiracleBros) was not able to navigate into the guide catheter.
- We attempted an antegrade trapping balloon with Runthrough wire to facilitate MiracleBros advancement into the guide but it wasn’t successful.
- MiracleBros 6 was then exchanged to Fielder which successfully entered into the RCA guide.
Wiring Technique
STEPS
- Balloon trapping and advancing Corsair catheter into the RCA guide catheter was subsequently performed.
STEPS
- Then, a long wire (i.e. ViperWire) was advanced via Corsair from LAD to RCA guide catheter, called wire externalization.
- Then, FineCross was advanced over the ViperWire, followed by a removal of Corsair and ViperWire.
- A Runthrough wire was negotiated via FineCross microcatheter into the RCA.
- Three DES were placed in the RCA with an excellent result.
Final Angiogram
Learning Points
- The case planning and selection of septal branch is paramount for procedural success.
- A hydrophilic wire with microcatheter can be used to navigate through the septal branch into the RCA, followed by wire escalation as needed.
- Manipulation of a stiff wire into the guide catheter is often challenging and a soft, hydrophilic wire (i.e. Fielder in this case) is highly recommended in these situations.
