Case 4: LAD CTO – D1 Bifurcation
Case Presentation
- A 64-year-old man presented with angina chest pain and dyspnea on exertion. Stress MPI showed anterior, apical, and septal ischemia.
- Coronary angiogram revealed 2V CAD (Prox LAD CTO bifurcation with D1{Medina 1,1,1}, LCx-OM2). LVEF was 60%.
- Medications: ASA 81 mg daily, Metoprolol XL 50mg daily, Amlodipine 5 mg daily, Atorvastatin 40mg daily
Case Analysis
PCI Strategy
- Length of CTO : < 20 mm
- Femoral approach
- 7F VL guide catheter
- Dual injection
- Antegrade approach with wire escalation (Fielder > MiracleBros > Gaia/Confianza 12), along with a microcatheter (i.e. FineCross)
- 2 stents strategy (Mini Crush)
Wiring Steps of LAD
- Started with Fielder and FineCross. Fielder (Asahi) didn’t cross the lesion, then changed to MiracleBros 6 (Straight tip-Asahi) for drilling. But failed to cross with MiracleBros 6.
- Exchanged to Gaia 3 as the CTO was short, angulated with bifurcation disease. However, it was not successful.
- Confianza 12 (tapered, hydrophilic coating, high tip stiffness) was used as a planned AWE and successfully crossed the CTO.
AWE (Fielder > MiracleBros 6)
Wiring Steps Of D1
- It was challenging to wire into D1 – branching vessel (Lower branch of D1).
- Superior branch of D1 was successfully wired with Fielder wire.
- Initial plan was to wire the lower branch of D1 with Runthrough and escalate to MiracleBros 3/6 with FineCross or Gaia series as needed.
- Finally, the lower branch of D1 was successfully negotiated with Runthrough.
Wiring Technique (AWE, SB wiring)
- Mini Crush technique with 2 DES was placed in LAD and D1 with an excellent result.
The case can be reviewed at https://ccclivecases.org/november-2017-ccc-live-case
Learning Points
- The operator should have a blueprint of AWE, although the choice of wires can be different among CTO operators.
- The operator had used AWE by using Fielder and FineCross > MiracleBros 6 > Gaia 3 > Confianza 12. Confianza 12 was finally crossed LAD-CTO segment in this case.
- In this challenging anatomy like angulated side branch, the wire should possess hydrophobic coated with excellent torqueability and sometimes, may require specialty CTO wires.
- First, we tried with Fielder (hydrophilic and polymer jacketed) but not able to navigate into the lower branch of LAD-D1.
- In this case, Runthrough (hydrophilic wire with distal 2mm hydrophobic silicone coating) was successfully negotiated into the lower branch of D1.
- We planned to use MiracleBros or Gaia series with FineCross microcatheter if Runthrough failed to cross the lesion.
