Case presentation. For the Philippines Chronic total occlusion (CTO) club. Audience will be Interventional cardiologist from Philippines. Guest speakers from Japan will join us. My case will be about a 46 year old man who came in for an elective PCI of an instent RCA CTO. His first PCI was last 2019 when he had a STEMI and a single stent was placed in the RCA. He presented with an 8-month history of anginal chest pains. His recent coronary angiogram showed total instent occlusion of the RCA at the proximal segment with the distal vessels supplied by collaterals from the the LCA. Initial CTO crossing strategy was antegrade approach with antegrade wire escalation and hydrodynamic contrast recanalization (HDR) as the specific techniques used. Dual injection showed a long RCA CTO starting from the proximal instent segment down to the distal bifurcation branches. Once the antegrade wire reached the distal vessel, it was very challenging to gain access to the distal landing zone as much of the distal vessels were small-calibered and diffusely diseased and visualization was very poor. We then switched to retrograde approach with wire crossing through the septal collateral from the LAD to the RPDA. Retrograde distal CTO cap puncture proved to be difficult as well because of the sharp angulation of the RPDA take off, with repeated preferential wire advancement into adjacent distal branches. Initial bailout techniques such as retrograde parallel wiring and antegrade distal marker wiring failed. Septal vessel balloon dilatation was then performed and 2.0 mm NC balloon was then advanced retrogradely into the RPL branch and CART technique was then performed which successfully facilitated antegrade wire access into the distal true lumen. Gaining access to the next distal bifurcation side branch was the next challenge as it was very challenging to gain antegrade distal access into this vessel. Parallel wiring and balloon blocking techniques were attempted but failed. A 2.0 mm NC balloon was again readvanced antegradely into the bifurcation segment and reverse CART technique was then performed which resulted in successful connection between then antegrade and retrograde spaces from the RPDA. Retrograde wire was then successfully advanced into the antegrade guidecatheter where a tip-in technique was subsequently performed and converted the retrograde system into an antegrade one. Conventional PCI was then performed. Hybrid treatment with DES and DCB was then applied in the distal bifurcation and overlapping DES deployed proximally in the main RCA vessel. This completed the procedure
Case presentation. For the Philippines Chronic total occlusion (CTO) club. Audience will be Interventional cardiologist from Philippines. Guest speakers from Japan will join us.
My case will be about a 46 year old man who came in for an elective PCI of an instent RCA CTO. His first PCI was last 2019 when he had a STEMI and a single stent was placed in the RCA. He presented with an 8-month history of anginal chest pains. His recent coronary angiogram showed total instent occlusion of the RCA at the proximal segment with the distal vessels supplied by collaterals from the the LCA.
Initial CTO crossing strategy was antegrade approach with antegrade wire escalation and hydrodynamic contrast recanalization (HDR) as the specific techniques used. Dual injection showed a long RCA CTO starting from the proximal instent segment down to the distal bifurcation branches. Once the antegrade wire reached the distal vessel, it was very challenging to gain access to the distal landing zone as much of the distal vessels were small-calibered and diffusely diseased and visualization was very poor. We then switched to retrograde approach with wire crossing through the septal collateral from the LAD to the RPDA. Retrograde distal CTO cap puncture proved to be difficult as well because of the sharp angulation of the RPDA take off, with repeated preferential wire advancement into adjacent distal branches. Initial bailout techniques such as retrograde parallel wiring and antegrade distal marker wiring failed. Septal vessel balloon dilatation was then performed and 2.0 mm NC balloon was then advanced retrogradely into the RPL branch and CART technique was then performed which successfully facilitated antegrade wire access into the distal true lumen. Gaining access to the next distal bifurcation side branch was the next challenge as it was very challenging to gain antegrade distal access into this vessel. Parallel wiring and balloon blocking techniques were attempted but failed. A 2.0 mm NC balloon was again readvanced antegradely into the bifurcation segment and reverse CART technique was then performed which resulted in successful connection between then antegrade and retrograde spaces from the RPDA. Retrograde wire was then successfully advanced into the antegrade guidecatheter where a tip-in technique was subsequently performed and converted the retrograde system into an antegrade one. Conventional PCI was then performed. Hybrid treatment with DES and DCB was then applied in the distal bifurcation and overlapping DES deployed proximally in the main RCA vessel. This completed the procedure
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This presentation details the complex case of a 46-year-old man with symptomatic RCA ISR-CTO following a STEMI PCI. It outlines the clinical history, angiographic anatomy, and strategic planning for dual injection and crossing attempts. The challenges faced during antegrade and retrograde approaches are discussed, highlighting the importance of adapting strategies based on anatomical considerations. Key techniques such as CART and reverse CART are explored, culminating in successful PCI...