Case 129: Manual of CTO Interventions - 3 vessel disease + RCA CTO

A patient with 3-vessel coronary artery disease declined CABG and was referred for PCI of the RCA CTO as well as the LAD/ramus/circumflex. PCI of the RCA CTO was attempted with antegrade wire escalation, however the wire entered the subintimal space. Re-entry attempts using the Stingray balloon failed despite using the bobsled, double-blind stick and swap, and STRAW technique. The LAD was stented followed by retrograde crossing attempts through a septal collateral. The collateral was crossed with a Suoh 03 guidewire, but the Corsair could not cross. A Cavavel catheter crossed, followed by successful retrograde crossing into the antegrade guide catheter, wire externalization and stenting of the RCA.
The left system had a trifurcation with disease in all 3 vessels (LAD, ramus, circumflex). They were all predilated, but after stenting the ramus, the circumflex occluded resulting in chest pain, ST-segment elevation and hypotension. The circumflex was predilated and stented over the jailed wire restoring flow and resolving the chest pain, ECG changes, and hemodynamic stability. After rewiring the LAD and ramus kissing balloon inflations were done with an excellent final result.

[@nctbkh3718]

Thanks for sharing! Jailing wire is important for immediate access to vessel, and guiding catheter stabilisation. You demonstrated and emphasized one more time. Trifucation lesions are very scary lesions especially for young interventionalists. I am looking forward seeing some trifucation interventions in your channel. Thank you!

[@tahersalman6698]

Thanks Prof

[@shangz0216]

Thanks for your sharing.

[@mohamedkishkt3667]

Thanks prof.