Case 234: Flush aorto-ostial CTO

An elderly women with prior CABG presented with recurrent failure of the SVG-RCA. She had a flush aorto-ostial CTO of the native right coronary artery. A primary retrograde approach was used. Using a Venture catheter a retrograde wire was advanced to the RCA ostium. Multiple highly penetrating wires could not puncture into the aorta. E-CART with 50W cut also failed. Multiple antegrade guides and penetrating wires were used but could not puncture through the proximal RCA. Eventually the SVG-RCA was stented.

[@shangz0216]

Thanks for the excellent case presentation.

[@hifa63]

Thanks for the educative case

[@DreamTheaterTomi]

Aorta is very horizontal. In my experience, the ostium could have a very strange course. I think coronary CTscan could 1) define the exact location and 2) define the exact fluoro-angle to restart anterograd approach.
Do you plan to bring back the pt for a next session?

[@manosbrilakis]

We did have a CTO scan that showed severe calcificaiton of the entire aortic wall.
No plans to bring her back unless she has recurrent ISR of the SVG.

[@NikhilJha89]

Can we do ivus in retrograde wire to locate proximal cap?

[@manosbrilakis]

Great idea but would be happy to be able to advance the IVUS retrogradely all the way to the RCA ostium.

[@NikhilJha89]

@@manosbrilakis sir do you use hybrid cath lab in which surgeon would do lima to lad by midcab and you do stenting of other vessels? How's your experience about hybrid labs?