Case 248: Manual of CTO PCI - Micro Rx

A patient presented with NSTEMI due to a severe lesion in a saphenous vein graft to the right posterior descending artery. The SVG lesions was treated with balloon angioplasty and the patient was referred for PCI of the native right coronary artery CTO. The SVG to the PDA was engaged with a multipurpose 8 French guide and the native RCA with an AL1 also 8 French guide using a bifemoral approach. The distal RCA CTO had a clear, tapered proximal cap, 40 mm length, bifurcation at the distal cap (PDA-right posterolateral) and the distal vessel was filling via the SVG-PDA. Antegrade wiring failed. The Carlino technique “softened” the proximal cap and a Fielder XT was subsequently knuckled across the CTO into the right posterolateral. To minimize the risk of occluding one of the side branches at the distal bifurcation we changed to retrograde crossing.
A retrograde Gaia Next 2 was advanced through a Sasuke dual lumen microcatheter and then through a Turnpike LP retrogradely into the distal RCA but the Turnpike LP and a Sapphire 1.0 mm balloon could not cross. A Micro Rx microcatheter was successfully advanced retrogradely into the distal RCA, followed by successful advancement of the Turnpike LP and successful guide extension reverse CART. After externalization and stenting into the PDA, flow into the right posterolateral was compromised but was subsequently restored after rewiring and balloon angioplasty. Due to significant competitive flow the SVG-PDA was coiled with a Penumbra coil.

[@KatherineMilan]

What a great concept of Microcatheter with Micro Rx. Very intuitive and practical design to address such cases in a very easy way. Looking forward to see it in Europe as well! Thank you for sharing this case Dr. Brilakis.

[@shangz0216]

Thanks for the excellent case presentation.

[@elmiraaghaee6550]

Hello professor Brilakis. Thanks for your teaching and sharing your experiences. Why did you recanalized RCA while SVG flow and distal RCA branches was TIMI 3 ?

[@tom11298]

RCA had a CTO distally, and recanalizing cto ,if feasible, is always a favorable option over PCi/stenting to SvG that is degenerative and started to fail and had stenosis at touch down. Also native pci has a better outcomes. Initial PTCA was only meant to open the vessel, with very high chance of re occlusion

[@manosbrilakis]

Great point - the likelihood of achieving long-term SVG patency after the SVG becomes completely occluded during an AMI is quite low.

[@user-su4he3ju7t]

Hi, Professor Emmanouil Brilakis. Can i ask one question? What about PLB of RCA? We used cutting balloon and avacuated intramural hematoma. Do we need stent covering from RCA to PLB in this situation?

[@manosbrilakis]

Another stent could be used but that increases the complexity of the procedure and the risk of restenosis.

[@mohamedaymenbenabdessalem1160]

Can we exchange wires through this device ?

[@manosbrilakis]

No