Case 230: Manual of CTO PCI - Overcoming challenges

A patient was referred for PCI of a right coronary artery CTO after 2 prior failed attempts. He had significant exertional dyspnea that was considered to be an anginal equivalent. The RCA had an anterior and downward takeoff and was very challenging to engage. Eventually it was engaged using an AL2 guide along with a guide extension. The CTO was a blunt proximal cap, long length, with a bifurcation at the distal cap and was filling via septal collaterals. A primary retrograde approach was used. The first septal was crossed with a Sion black guidewire but the wire advanced antegrade instead of retrograde. The Coraflex microcatheter was advanced distally in the septal and a Fielder XT-R was successfully directed towards the distal RCA. The Coraflex could not cross the septal but eventually using a guide extension a Corsair XS was advanced to the distal RCA. A Gladius Mongo was advanced to the proximal RCA. Antegrade wiring attempts using the retrograde knuckle was target were challenging, as the proximal vessel was big and guide support was poor. Balloon-assisted subintimal entry (BASE) using a 5.0 balloon failed, but eventually usually the Carlino technique a Gaia Next 2 wire was advanced to the mid RCA, followed by successful guide-extension reverse CART. The Corsair XS could not advance to the antegrade guide extension, but a FineCross did advance, followed by wire externalization, and stenting.

[@Sradhananda15]

Fantastic 8 minutes presentation for a 400 minutes procedure... Patience.. persistence commendable.🙏👌

[@shangz0216]

Thanks for the excellent case sharing.

[@hifa63]

Thanks Professor

[@jwilson3985]

6+hr procedure?! Wow. Was the patient under GA or how did they lie flat that long? What was the sedation plan and did it change throughout?

[@fattybum316]

Nice case. How do you decide between switching retro microcatheters or doing rendezvous if you cannot advance the retro MC through the CTO?

[@manosbrilakis]

Rendez vous is very hard to do - it only works if both antegrade and retrograde wire is in the same space (intraplaque or extraplaque) - in most cases when we cannot deliver the microcatheter through the collateral we insert a guide extension and change the microcatheter.

[@fattybum316]

Sorry I meant tip in, in the antegrade guide