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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

Case Overview

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.

ModelBurst (ATM)Diameter (mm)Balloon Length (mm)              
681215202530
MINI TREK (CTO INDICATED)1.271.2
1.561.5
2.172✓*✓*
TREK2.372.25
2.672.5
2.912.75
3.113
3.53.25
3.73.5
3.943.75
4.324
4.864.5
5.365
*Only available as RX, not as OTW. Other sizes available in both versions.
Retrieved on April 07 2022 from Abbott product ordering information. Please look at the company's files for the latest available data on device configurations and avilability in your area.

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