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Case 5: Complex Proximal RCA CTO ISR Via Antegrade Approach Followed By Laser Atherectomy And Atherotomy

Case 5: Complex Proximal RCA CTO ISR Via Antegrade Approach Followed By Laser Atherectomy And Atherotomy

Case Presentation

A 72-year-old man presented with left sided angina and shortness of breath. Stress MPI showed moderate inferior and inferolateral ischemia.
Medical history: 3V CAD s/p multiple PCIs and s/p CABG (LIMA to LAD, SVG to RCA, SVG to Ramus, SVG to LCx-OM1), Hypertension, Hyperlipidemia, NIDDM.
Medications: ASA 81mg, Clopidogrel 75mg, Amlodipine 10mg, Lisinopril 10mg, Metoprolol XL 50mg, Aldactone 25mg, Glipizide ER 10mg
Coronary angiogram showed patent LIMA to LAD but all vein grafts were closed. PCI to LCx and PTCA of Ramus was done.
Planned to do ISR CTO of RCA intervention due to persistent symptoms with maximal medical therapy.

CTO length : < 20 mm, blunt stump, collateral++
Femoral approach
Dual injection, AL 0.75 6F for RCA, 5F JL for LAD.
Antegrade approach with AWE (Fielder > Gaia3 > Confianza 12) along with a microcatheter
If failed, will attempt retrograde approach
May need Rotational or Laser atherectomy

Started the procedure with Fielder/FineCross. Fielder wire successfully crossed in-stent RCA CTO via microchannel.
As a part wire de-escalation strategy, Fielder was exchanged with Runthrough wire.
Laser atherectomy was performed by using 80 mJ/mm² and 80Hz, followed by sequential balloon inflation.
IVUS of RCA revealed a significant intimal hyperplasia.

Prox RCA had MLA of 3.6 mm². Mid and distal RCA had two stent layers with significant intimal hyperplasia.

With the presence of significant intimal hyperplasia, cutting balloon PTCA was done; followed by the placement of two DES in RCA with an excellent result.

ISR CTO wiring can be difficult in some cases and may even require a stiffer wire with higher tip load, like Astato 20 or 40. In this case, Fielder and FineCross was successfully crossed the CTO lesion.
Lesion modification (Atherectomy/Atherotomy) is paramount in ISR-CTO after wire crossing.
Laser atherectomy is particularly useful for lesion modification in balloon un-crossable lesion.
Imaging guided PCI is highly recommended to evaluate the etiology of ISR CTO.