Case 216: Manual of CTO PCI - The stain...

A patient was referred for PCI of a right coronary artery chronic total occlusion with an ambiguous proximal cap at the takeoff of an acute marginal branch. A primary retrograde approach was used. Wiring of the first septal was successful but a Turnpike LP and a Caravel microcatheter could not be delivered despite using a 6 French Guideliner Coast. We removed the guidewire and successfully crossed a more distal septal collateral, through which we were able to easily advance a Caravel microcatheter. Guide extension reverse CART was successful followed by externalization of an R350 guidewire. We stented with a 3.0x48 mm Synergy but there would poor antegrade flow, likely due to distal edge dissection. Using a Sasuke microcatheter and a Sion black wire we wired the right posterolateral branch and performed balloon angioplasty of the distal RCA. Angiography showed a "stain" likely due to small vessel perforation during wiring attempts. Prolonged balloon inflations resulted in decrease in the "stain". We considered placing a coil using the "block and deliver" technique but the perforated branch was too small. There was no pericardial effusion by echocardiography. After removing the wires and balloons and administering 30 mg of heparin the perforation was sealed. The patient had an uneventful recovery.

[@shangz0216]

Thanks for the excellent case sharing.

[@drmz2007]

Excellent case sir So many learning points

[@drvivekm05]

Why not used IVL