Case 224: Manual of CTO PCI - Just marker

A patient with ischemic cardiomyopathy and 3-vessel coronary artery disease (LAD chronic total occlusion, RCA multiple lesions, CTO of small circumflex that was non-viable by MRI - LAD and RCA territories were viable) was referred for PCI after being turned down for CABG. Given ejection fraction of 35% an Impella CP device was inserted prophylactically, followed by successful PCI of the RCA. Retrograde crossing of the LAD CTO via septals failed, as did IVUS-guided antegrade puncture. A Suoh 03 wire was advanced through an apical epicardial collateral from the PDA to the LAD. The retrograde wire kept on entering into the extraplaque space distal to the distal cap. Multiple attempts to redirect the retrograde guidewire into the true lumen failed. The retrograde wire was advanced extraplaque next to the proximal cap and served as marker ("just marker" technique) for advancement of an antegrade Gaia Next 2 and a Gladius Mongo wire into the distal true lumen of the 2nd diagonal. Using a Sasuke dual lumen microcatheter a workhorse wire was advanced to the distal LAD, followed by stenting with an excellent final result and preservation of two large diagonal branches.

[@drmz2007]

Excellent demonstration of just marker wire technique.
Thank you

[@shangz0216]

Thanks for the educative case presentation.

[@SukruAkyuz]

A good case again. Thank you.

[@hifa63]

Thanks

[@dobryi_chel]

thanks for amazing education case, professor Brilakis! How Do you think it was possible to manage only with stenting of the right coronary artery, since there is a large epicardial collateral passing through the apex of the heart?

[@manosbrilakis]

Good point - even large collaterals do not provide full perfusion - FFR post wiring crossing of such CTOs is almost always