Case 123: Manual of CTO Interventions: Proximal cap ambiguity + reverse CART troubleshooting

A patient with ischemic cardiomyopathy was referred for PCI of a right coronary artery chronic total occlusion. Right heart catheterization was performed showing PA systolic pressure in the 30s, hence no hemodynamic support device was used. PA pressure monitoring was performed throughout the case.
CT angiography had revealed a blunt proximal cap at the takeoff of an acute marginal branch. Using CTA coregistration and IVUS guidance (IVUS in the acute marginal) the proximal cap was successfully punctured, but the guidewire could not cross past the mid RCA. Retrograde septal crossing was performed, followed by Guideliner reverse CART using the DRAFT technique (Deflate, Retract, and Advance into the Fenestration, created by Mauro Carlino). After stent placement and stent optimization using IVUS, successful recanalization of the RCA was achieved.

[@AhmedElborae]

Thanks Dr Manos for this informative case. I want to ask about CT co-registeration, Does it need certain software or available on certain type of cath machine? Thanks alot

[@manosbrilakis]

CT coregistration is done through Siemens software. Here is a recent publication from Farouc Jaffer's group": www.ncbi.nlm.nih.gov/pubmed/27663227