Case 208: Manual of CTO PCI - Double Stingray

A patient with medically refractory angina was referred for PCI of a mid RCA CTO. The CTO was at the takeoff of an acute marginal branch and the distal vessel was diffusely diseased and calcified with bifurcation close to the distal cap. IVUS in the acute marginal was not very useful for locating the entry point to the mid RCA proximal cap due to severe calcification. A knuckles guidewire was advanced to the distal RCA but reentry attempts with a Stingray balloon failed. Retrograde crossing was successful through a septal branch but the septal could not be crossed with a microcatheter. We crossed an epicardial collateral from the circumflex into the right posterolateral but could not advance the guidewire to the distal RCA (it kept advancing distally). Eventually we knuckled wires antegradely into both the PDA and the right posterolateral and did reeentry into each vessel with a Stingray balloon followed by DK crush stenting with a nice final result.

[@shangz0216]

Thanks for the excellent case presentation.

[@ruotianli8785]

Thanks for the great case as usual. In this case, where a "flap" between the PL wire and the PD wire existed, is it always safe to perform DK crush, in order to maintain both branches? I think I would have done an investment and defer the stenting. What do you think?

[@manosbrilakis]

DK crush is the safest approach in such cases, as the position of the main vessel wire is maintained throughout the procedure - in culotte the main vessel is rewired which may lead to extraplaque crossing and failure to achieve patency of the main vessel.