Case 219: Manual of CTO PCI - ISR CTO with bifurcation

A patient with prior CABG presented with CCS class III angina in the setting of RCA and circumflex CTO with viability in both territories. The RCA CTO had an ambiguous proximal cap and was filling distally via both bridging ipsilateral as well as epicardial contralateral collaterals. Retrograde and antegrade crossing attempts failed and the patients had chest pain and ST segment depressions, likely due to ischemia from a guide catheter extension. We decided to attempt to recanalize the circumflex in-stent CTO instead. The circumflex was occluded proximally; there were prior stents into both the OM1 and the distal circumflex. We wired into the OM1 using a Gaia 2nd and Mongo guidewire but the occlusion was microcatheter uncrossable. Using the side branch anchor technique with a balloon in the septal branch and a 1.5 mm Takeru balloon the OM1 lesion was crossed and predilated. We then wired into the distal circumflex using a Gaia Next 2 and a Gladius Mongo wire. After ballooning into the circumflex we had difficulty advancing balloons into the OM1, which was eventually overcome using laser. We stented into the OM1, which resulted in occlusion of the distal circumflex (that contained a jailed wire). Rewiring the distal circumflex failed through the Sasuke but succeeded through a Corsair microcatheter with a Gaia Next 2 wire. Lithotripsy was done due to balloon under-expansion in the distal circumflex, followed by kissing balloon inflations with a nice final result. There was a dissection in the proximal LAD that was successfully stented.

[@shangz0216]

Thanks for the educative case presentation.

[@mahmoud_elrayes]

Excellent case. What are the collaterals supplying LCX? Thanks