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.
Case Analysis and Planning
PCI Strategy (ISR-CTO)
- 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
STEPS
- 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.
CTO Crossing With Fielder/FineCross
Laser Atherectomy
IVUS
- Prox RCA had MLA of 3.6 mm2. Mid and distal RCA had two stent layers with significant intimal hyperplasia.
Cutting balloon PTCA and DES
- 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.
Final Angiogram
Learning Points
- 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.
