Case 212: Manual of CTO PCI - The 2nd time is the charm!

A patient was referred for PCI of a RCA CTO due to medically refractory angina. The RCA CTO had an ambiguous proximal cap, length of approximately 40-50 mm, a bifurcation at the distal cap, and both ipsilateral bridging and contralateral (septal and epicardial collaterals). A primary retrograde approach was used due to the proximal cap ambiguity. A septal collateral was crossed but exited close to the distal cap and was abandoned. Attempts for crossing other septal collaterals and an epicardial collateral failed. Eventually a wire was advanced retrogradely through a septal to the PDA/PLV bifurcation but attempts to puncture the distal cap failed due to poor guide support. The procedure was stopped due to high radiation dose (4 Gray).
A coronary CT angiogram showed tapered proximal cap without significant calcification and severe calcification at the distal cap. A repeat RCA CTO PCI attempt was done 8 weeks later. Bilateral femoral access was used with 8 French guide catheters. We punctured the proximal cap and advanced a knuckled Gladius Mongo wire to the distal cap. We then crossed retrogradely with a Sion black and delivered a Caravel microcatheter. Despite using multiple highly penetrating guidewires and a guide extension we could not puncture the distal cap. We changed to a Turnpike LP microcatheter and eventually punctured the distal cap using the antegrade knuckle as marker. We had difficuly with reverse CART, requiring redirecting the retrograde wire in the RAO projection. We also did IVUS that demonstrated extraplaque position for the retrograde wire and intraplaque for the antegrade wire. After using a 4.0 mm antegrade balloon, guide extension reverse CART was successfully completed, followed by guidewire externalization and stenting with a nice final result.

[@shangz0216]

Thanks for the educative case presentation.

[@ruotianli8785]

Wow! This is a really hard case. Congradulations!

[@ahmettemiz2528]

Super as always

[@vigyanbang]

How do you inject thru a microcatheter? It seems like an autoinjector like Acist. If so, what settings do you use?

[@manosbrilakis]

We use a 3 cc Medallion syringe.

[@praveenalane4331]

Which way do you usually go if you fail to pass through a septal ..Do you go for another septal distally or you come proximally ?

[@manosbrilakis]

Good question: it all depends on the anatomy, will usually go for the largest and more direct connection.