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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.

Left Main DK Crush Video ID