Case 170: Manual of CTO PCI - Retrograde LAD CTO PCI and DK crush for quadrification

A patient with prior anterior MI but with viability of most of the anterior wall was referred for PCI of an LAD CTO. We tried to advance a Samurai RC wire into the ramus branch at the proximal cap, but the guidewire advanced through the occlusion into a large first diagonal branch. Antegrade crossing attempts of the LAD failed. We were unable to advance an IVUS catheter to help clarify the proximal cap ambiguity. We were successful with retrograde crossing via a septal collateral, followed by “true-to-true” crossing of the proximal LAD into the left main and externalization of an R350 guidewire. We were unable to advance a guidewire to the mid and distal LAD due to diffuse disease. After inserting an antegrade guidewire to the proximal LAD we removed the externalization guidewire leaving the microcatheter into the septal branch.
The patient had a quadrification at the distal left main (LAD, diagonal, ramus, circumflex). We decided to stent using the DK crush technique because the ramus and circumflex did not have significant disease. The LAD was the side branch and the diagonal the main vessel. A stent was placed in the proximal LAD but we were unable to rewire the LAD despite using multiple antegrade guidewires and microcatheters. We were able to advance a retrograde guidewire into the LAD, followed by “tip in” with an antegrade Corsair that was advanced across the LAD stent. After inserting an antegrade guidewire and removing the Corsair the first kissing balloon inflation was performed. A stent was placed from the left main into the diagonal branch. Once again rewiring of the LAD was very challenging and failed despite using multiple guidewires and microcatheters in both the antegrade and retrograde direction. The main vessel stent was postdilated with excellent antegrade flow into the diagonal.

[@shangz0216]

Thanks for the educative case presentation.

[@alomarymsami]

I think the presumed Diagonal is in fact the LAD and the other branch is big 1st septal. Interesting case. CTCA would help to clarify.

[@tom11298]

Interesting, great case. I assume a large dominant 1st septal is there. The presumed diagonal is possibly the LAD that continues beyond the apex.

[@muhammadyolandisumadio1547]

I second this

[@rh3374]

Looks like the LAD has TIMI 3 flow out to and around the apex, with a large septal with multiple branches having the sluggish flow.

[@karthikeyanselvaraj1801]

Sir xcellent case demonstration as ever..will LAO cranial view be of any help to determine to rule in the presumed Diagonal as LAD or the other way round?..

[@user-su4he3ju7t]

Great case, thank You very much. Can we use IVUS after stent deployment in diagonal branch to assess the wire enter in LAD, for the second kissing, or it will be do in second step, in next procedure?