Case 244: Manual of CTO PCI - The 3rd time is the charm!

A patient was referred for PCI of an ostial RCA CTO due to exertional dyspnea and angina after an unsuccessful recanalization attempt. The retrograde approach was attempted through a septal collateral, however the branch entered by the microcatheter was epicardial, resulting in distal wire perforation. After placement of an Axium coil hemostasis was achieved and the procedure was stopped.
The patient returned for a repeat attempt 6 weeks later. Antegrade wiring attempts failed. Attempts to enter the septal collaterals were challenging but eventually succeeded by leaving a wire in a non-connecting branch as marker of where not to go and using a dual lumen microcatheter. The septal was successfully crossed followed by microcatheter advancement all the way to the RCA ostium. Attempts to puncture into the aorta with various wires failed, despite using the Carlino technique. Engagement of the RCA was challenging but eventually it was successful using an 8 Fr Hockeystick guide. Using the Carlino technique allowed partial advancement of a microcatheter. Eventually a Fielder XT wire knuckled to the mid RCA, followed by successful guide extension reverse CART. After wire externalization the proximal RCA was balloon undilatable despite intravascular lithotripsy. Eventually the lesion was expanded uing an SIS-OPN balloon at 45 atm with a nice final result. The patient’s symptoms subsequently resolved.

[@shangz0216]

Thanks for the excellent case sharing.

[@ramikafa]

Great case. Thank you

[@DanPascut]

Can you show how to always tell the septals apart from epicardials?

[@user-di2sx1ll1i]

Thank you very much for sharing this case. I have a question: what about conus branch? TIMI I flow (Could it cause collapse later?)

[@user-rx5xv9vl7z]

You are awesome

[@NikhilJha89]

Excellent case
Was general anaesthesia used? Because It’s difficult for patients to lie down for 6 7 hours

[@manosbrilakis]

Moderate sedation was used - you are right that some patients may require anesthesia for prolonged procedures.