Case 214: Manual of CTO PCI - open sesame

A patient with a CTO of both the RCA and the ostial circumflex along with distal left main disease was referred for PCI. The plan was to recanalize the circumflex first. A wire was inserted into the LAD and a branch that appeared to be the ramus but was actually a diagonal. We tried to do IVUS to clarify proximal cap ambiguity but the IVUS would not cross. Balloon angioplasty was done into the diagonal followed by restoration of some antegrade flow into the circumflex (open sesame technique).
A Sasuke dual lumen microcatheter was used to advance a wire into the obtuse marginal, followed by balloon dilatation. However, the wire had gone into a small side branch and balloon inflation caused a small perforation that was sealed with 2 Axium coils after wiring the true OM1. T-stenting was performed with a stent advanced from the ostial LAD into the diagonal branch (LAD was occluded). A stent was then deployed from the circumflex in to the left main, followed by rewiring of the LAD/diagonal and kissing balloon inflation. The OM1 ostium was compromised and was treated with a stent using the TAP (T and protrusion) technique with a nice final result.

[@shangz0216]

Thanks for the educative case presentation.

[@drmz2007]

Excellent case sir Can we use DEB in place of side branch stenting?

[@manosbrilakis]

Yes, great idea - DCBs are not yet available in the US