Case 252: Manual of CTO PCI - Rota-Tripsy for a heavily calcified CTO

A patient presented with exertional dyspnea due to a RCA CTO and a mid LAD lesion. He underwent an unsuccessful attempt for RCA CTO recanalization and was referred for a 2nd attempt. He had a mid RCA CTO with heavy calcification, clear proximal cap, short length of ~10 mm, diffusely diseased distal vessel and a PDA filling via an epicardial collateral through the diagonal branch. Antegrade wiring with a Gladius Mongo resulted in extraplaque crossing. The epicardial collateral was successfully crossed with a Suoh 03 guidewire, but the Caravel microcatheter could not cross. The retrograde wire was used as marker (“just marker” technique) for the antegrade wire. A Gaia Next 2 successfully crossed into the distal true lumen. Delivery of a 1.5 mm burr through the Trapliner failed and resulted in rupture of the Trapliner balloon. After removal of the Trapliner multiple runs of rotational atherectomy were performed. The vessel remained balloon undilatable, hence intravascular lithotripsy was performed with good expansion. After RCA stenting a nice final result was achieved.

[@shangz0216]

Thanks for the excellent case sharing.

[@drstepi]

Excellent case - I appreciate the techniques you implemented in this case and have a few questions -how did you introduce Rotawire if the lesion was uncrossable - parallel technique or were you able to push some sort of MC distally? Rotawire manipulation is quite difficult. And second question - did you use imaging to prove integrate and retrograde wire position or just plain angio? Thank you and as usually I can't wait for next episode from you.

[@ahmedzahran7016]

excellent case, Can removing the trapliner and then rewiring again cause issues? and what about deflating the trapliner balloon before advancing the rota? do you like to use DCB for the PDA?,