Case 6: Mid RCA CTO via Antegrade Recanalization
Case Presentation
- A 48-year-old man presented with CCS class 1 angina. Nuclear stress test showed moderate to severe lateral and inferior walls ischemia.
- Coronary angiogram showed 2 V CAD (mid RCA CTO and LCx-OM) and had PCI to LCx-OM. LVEF was 50%.
- Medical history: HTN, HLD, NIDDM, Current smoker, ESRD on HD
- Medications: ASA, Plavix, Amlodipine 10mg, Metoprolol XL 50mg, Lisinopril 10mg, Fenofibrate (Statin intolerance)
Case Analysis and Planning
PCI Strategy
- CTO length < 20 cm, branch vessel+ near the proximal cap
- Blunt stump, no good septal collaterals, 1st septal had straight course
- Dual injection (6F LIMA guide –RCA, JL for LCA)
- If the guide was not stable, would use 7F or AL 0.75 guide
- Antegrade approach with AWE (Fielder/Fielder XT > Gaia 3 > Confianza 12) along with a microcatheter
- If antegrade failed, would consider retrograde approach
STEPS
- First, Fielder with FineCross was used but Fielder wire went to a side branch.
- Then, escalated to Gaia 3 (tapered, hydrophilic coating, high tip stiffness).
- Gaia 3 crossed the lesion and advanced FineCross to the distal part of RCA.
- Exchanged with Runthrough (workhorse wire), followed by serial balloon dilatation. One DES was placed in mid-RCA with a good result.
Wiring Technique
The case can be reviewed at https://ccclivecases.org/may-2018-ccc-live-case
Final Angiogram
Learning Points
- The choice of AWE in this case were Fielder/Fielder XT > Gaia 3 > Confianza 12.
- Fielder/Fielder XT (low penetration force 0.3-1.7g) is particularly useful for micro-channel tracking, passive sliding wire control whereas Gaia family (intermediate penetration force 3-4.5 g) is for active wire control (rotation/deflection), fibrocalcific plaque tracking (intimal or subintimal).
- If a microcatheter doesn’t advance over the wire, we can remove the microcatheter by wire trapping with balloon inflation inside the guide. Then use the lowest profile balloon (1.0 balloon or 1.25 balloon) with serial balloon dilatation for lesion preparation.
- If necessary, laser atherectomy can be used in balloon un-crossable lesion.
