Case 171: Manual of CTO PCI - Longest case

A patient with severe peripheral arterial disease in need of peripheral artery revascularization was referred for multivessel PCI: he had an ostial LAD CTO, distal left main and ostial circumflex lesions and a mid right coronary artery lesion. His ejection fraction was 48% by cardiac MRI with viability of most myocardial territories.
We obtained right femoral and right radial access. We were unable to engage via radial access and obtained left femoral access. PCI of the RCA was challenging due to severe tortuosity and calcification. After orbital atherectomy, predilation and use of a 6 Fr guide extension the mid and proximal RCA were successfully stented.
A primary retrograde approach was followed for the LAD CTO given distal left main and ostial circumflex disease and proximal cap ambiguity. Retrograde crossing was challenging but succeeded using various guidewires (Suoh 03, Sion black, Fielder XTR). We could not advance a Corsair XS to the LAD but were able to advance a Turnpike LP and did tip injection. We advanced a guidewire subintimally to the proximal LAD clarifying the proximal cap ambiguity, followed by LAD antegrade subintimal wiring with a Gaia 3rd. We had difficulty advancing the 6 Fr Telescope to the proximal LAD despite multiple balloon dilations and the tip broke off. We were unable to retrieve it using the small balloon technique. We inflated a 2.5x8 mm balloon and pulled back the wire and the lost fragment that bounced off the left femoral sheath and embolized in the iliac artery.
We advanced a Guidezilla into the LAD and completed guide extension reverse CART followed by externalization of an R350 guidewire. The patient developed chest pain and ST elevation. Angiography showed a filling defect in the distal RCA distal to the prior stents. We tried to deliver a stent but had stent loss. The stent was deployed. The tip of the guide extension also fractured. We have extreme difficulty advancing equipment through the mid RCA but after using multiple balloons and another guide extension we successfully delivered and deployed stents distally.
We used a Sasuke to wire the mid LAD, followed by removal of the externalized guidewire. The left main, LAD and circumflex were successfully stented using the DK crush technique. An area of staining in the mid LAD was covered by a PK Papyrus covered stent. Additional stents was placed distally in the mid LAD and in the left main ostium.
After completion of the PCI the lower extremities appeared cool, hence vascular surgery evaluation was requested without finding any new peripheral arterial lesions. The femoral sheaths were removed and manual pressure was held, but the patient developed a right groin hematoma followed by hemodynamic collapse requiring intubation and CPR. He was subsequently placed on VA-ECMO after obtaining repeat left femoral arterial access. Coronary angiography showed patent vessels. A graft was sutured in the right iliac artery and the arterial cannula was changed to the right groin.
The patient was subsequently decannulated and extubated. He had normal ejection fraction and was neurologically intact and was eventually discharged to rehabilitation.

[@viktorsasi7453]

Dear Manos! Congratulations for the great team effort to save the patient’s life. It is always awesome to learn treating difficult scenarios. Thank You

[@mustaphanacerbey8284]

What a case !!! Very challenging case with complexe lesions, the RCA with his tortuosity and calcification make the procedure very difficult, thanks for extension and atherectomie and specially operators ability to resolve this case... Special thanks for anesthesit

[@bassemzarif3444]

Really amazing work. A lot of technical issues. Thanks mannos

[@karthikeyanselvaraj1801]

U r really an interventional God for people like us..showin us the way how to accept things fast... to fight it out nd never back down.. really amazing.. thanks a lot for cultivating such habits in us🙏🙏🙏

[@balbirsingh932]

Congratulations to your team for saving precious life

[@praveenalane4331]

No wonder …a well preserved EF will always help patient how complex the procedure is … Great case and excellent teaching points as usual professor

[@aasaad007]

Salute to all the team members and especially you on doing very challenging case ....from Pakistan

[@hatebankers]

Very didactic case. Thanks for sharing. Many lessons learnt as you beautifully summarized.

[@Stentordoc]

As a cardiologist in private practice, it would have taken me an extra hour just to figure out the billing for that case 😂

[@Cosmicforon]

ahahahahahhaha

[@stanislavdolgov5071]

Thank you for your excellent case! Hardest work! I think that for more comfortable work we shall need to separating procedure for some steps in the future and don’t hesitate to use IVUS to prevent complications and additional stents in that complex cases.

[@shangz0216]

Thanks for the educative case presentation.

[@micger]

Holy moley this is the mother of all cases. I admire your perserverance Manos. I have so many questions but the one that comes to mind is that do you think Telescope is more likely to have a fractured tip compared to the other guide extension catheter? Would you use Telescope again in a complex case?

[@manosbrilakis]

Good question: since this case I have not used Telescope in heavily calcified lesions.

[@bahaeddinattamimi1313]

Unfortunately in the lessons mentioned, He did not mention the need for CABG, 3 v CAD with a CTO, high Syntax score, and ischemic CMP. If he felt the pt was not a good candidate for CABG then stent RCA and LM LCX, then see how he does with a single vessel CAD and good collaterals. Then stage CTO LAD later. Maybe it’s better to discuss these cases in a heartbreak approach before embarking on a complex PCI

[@bahaeddinattamimi1313]

Heart team approach *

[@drezaldin3516]

@@bahaeddinattamimi1313 the case was highly suggestive CABG but here in our its for the patient choice, maybe the patient preferred PCI

[@manosbrilakis]

Good point - the patient was discussed by the heart team and the decision was for PCI. Agree with you that deciding what is the optimal extent of revascularization is important - at the same time stenting the left main/circumflex would make LAD PCI much harder.

[@usetherightbrain.]

Whew, clearly the "War and Peace" of Interventional cases-Could have been a shorter case by fixing the RCA and the LMCA/ostial LCX only- 10 ICs in the room and 15 opinions, I'm sure

[@drezaldin3516]

how can I get the book pls?

[@manosbrilakis]

www.elsevier.com/books/manual-of-chronic-total-occlusion-interventions/brilakis/978-0-12-809929-2

[@drezaldin3516]

@@manosbrilakis thank you doctor

[@schiefix]

Wow, what a shit case. Thanks for showing that, reassures us mortal PCI technicians that shit like that also happens to the PCI gods.... :)