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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


  • 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


  • 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.

Left Main DK Crush Video ID