Case 213: Manual of CTO PCI - LAD in-stent CTO with occluded LIMA

A patient with prior CABG twice (LIMA-LAD and SVG-LAD - both occluded) was referred for PCI of an LAD in-stent CTO. The LIMA was filling via collaterals from the costocervical trunk. Antegrade wiring was challenging (wire impenetrable lesion) but was eventually successful with an Astato 20 wire through a Turnpike LP microcatheter using orthogonal projections to verify that the wire was coursing inside the prior stent. The lesion was also microcatheter uncrossable, which was solved using a guide extension, a Sapphire Pro and a Threader balloon. The mid LAD was balloon undilatable but expanded after using intravascular lithotripsy with a nice final result after stenting.

[@shangz0216]

Thanks for the educative case presentation.

[@amrhanafymahmoud9829]

and by the way great as usual thank you for your suuport

[@fatherabdul]

Superb

[@amrhanafymahmoud9829]

sorry sir may i ask about using stent boost while stiff wire with ballon into stent to check postion of wire intra or extra stent

[@manosbrilakis]

Thank you - great point - agree that stent boost and clear stent can be very useful but orthogonal projections remain critical.