Case 233: Microcatheter uncrossable CTO

A prior CABG patient was referred for PCI of an LAD CTO due to medically refractory angina. He had an occluded SVG-LAD and anterior ischemia on nuclear stress test. Antegrade wiring resulted in crossing into a diagonal branch at the proximal cap. Side-BASE failed. We successfully crossed the occluded SVG-LAD with a Mongo wire. We were unable to advance a guidewire retrograde with a SuperCross 120 but were able to advance a Pilot 200 retrogradely via a ReCross dual lumen microcatheter. Guide extension reverse CART was successfully performed but the retrograde Corsair could not cross the CTO. We tried multiple small balloons and microcatheters without success. Antegrade external plaque crush failed as did repeat attempts for retrograde crossing. The proximal segment of the SVG-LAD was stented with plans with repeat PCI attempt of the LAD CTO.

[@shangz0216]

Thanks for the excellent case presentation.

[@magisrb]

Tip in and try antegrade crossing of MC, a longshot but I would try

[@ruotianli8785]

Blimp might have been a choice!

[@NikhilJha89]

Please Can you also show your hands to know how you handle so many equipments together

[@DreamTheaterTomi]

It is reasonable to blame the distal cap for failing mc-crossing. However, retrograd mc had a very tortuous course. At the anastomosis, the angle might be too acute to take. Pplying more power would push mc distally causing mc kinking. Was there any damage on the body of the mc?
Many thx for your cases,

[@manosbrilakis]

No damage on the microcatheter- great point re: tortuosity.

[@mahmoud_elrayes]

Thanks a lot for this case. Why did not you go retrogradely from RCA first? And what is your opinion of using LASER through retrograde wire?

[@jwilson3985]

Laser would never go around the corner from SVG into native. No chance.