Case 198: Manual of CTO PCI - It takes time...

A patient was referred for PCI of an RCA CTO due to medically refractory angina. The RCA was heavily calcified with an ambiguous proximal cap at the origin or a large acute marginal, short occlusion length, good quality distal vessel and septal/epicardial collaterals. Antegrade wiring entered into the acute marginal. Parallel wiring with a Sasuke failed, but a Gladius Mongo eventually entered into the extraplaque space distal to the occlusion. Delivery of a Stingray was challenging, but was eventually successful using a 7 French Trapliner, predilatation with a 1.0 mm Sapphire balloon, use of a Miracle 3 wire and use of a new Stingray balloon. The distal true lumen was successfully entered using the "stick and drive" technique with a Gaia 3rd wire, followed by stenting that was optimized with IVUS and use of an Ostial Flash balloon. A nice final result was achieved.

[@shahruhabdirimov3272]

Dr. Brilakis thanks for great cases.

[@shangz0216]

Thanks for the educative case presentation.

[@svijaykumarreddy1242]

good case

[@maherhalak4307]

Thank you so much Is there Stent-Fraktur in proximal RCA?

[@shahruhabdirimov3272]

Have questions, can you send some electronic books for download please

[@moatazshebl738]

Very heroic procedure actually , but question about the marginal branch in the first projection was it lost?

[@dipaklenka9611]

Yes the large AC Marginal was lost. Any hemodynamic change expected?

[@manosbrilakis]

Good questions. The acute marginal branch was indeed lost but the patient did not have chest pain or hemodynamic consequences. However, especially in patients with heart failure loss of an acute marginal branch can have clinically important consequences: see CTO Manual case 138: kzbin.info/www/bejne/h3KxqqaNbtt8e5I

[@maherhalak4307]

Thank you so much Is there Stent-Fraktur in proximal RCA?

[@manosbrilakis]

There is no stent fracture - what you are likely seeing is non round stent expansion in the proximal RCA due to calcification. Stent area was fine by IVUS.