LCH

A 66-year-old male, with diabetes mellitus, hypothyroidism and dyslipidemia came to hospital complaining of persistent dyspnea on exertion that lasted 1 year. He was non-smoker. Initial vital sign was as follows. The right arm blood pressure was 95/65 mmHg, and left arm blood pressure was 79/53 mmHg. There was a differnce in blood pressure between the arms.

He had a chest computed tomography(CT) scan, and there was significant coronary artery calcification. Electrocardiogram(ECG) showed normal sinus rhythm. cardiac enzymes were within the normal range.Natriuretic peptide (NP) was also within the normal range.Transthoracic echocardiography(TTE) showed no regional wall motion abnormality and ejection fraction was preserved (58%).

Coronary angiography (CAG) showed proximal right coronary artery (RCA) chronic total occlusion (CTO) withcontralateral collateral flow grade 2 from left anterior descending artery(LAD).Proximal LAD had diffuse irregular 80% stenosis with severe calcification and proximal left circumflex artery(LCX) had diffuse irregular 80% stenosis. with severe calcification. 
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So we tried to check left internal mammaryartery(LIMA) due to possibility of coronary artery bypass graft(CABG). But leftsubclavian artery (SCA) total occlusion was seen. So we checked right internal mammary artery(RIMA). Right SCA also had significant stenosis. For this patient, there was no option otherthan CABG but percutaneous coronary intervention(PCI), So we planned staged PCI. We punctured both femoral arteries with 7Fr arrow long introducer sheath (24cm) and used 7Fr JR 3.5(Cordis) and 7Fr  (Cordis) 3.5 for backup support. First, We implantated a stent from LAD ostium to proximal LAD lesions with Orsiro mission(BIOTRONIK) 3.0/22 mm foreasy wiring of septal channels. And we tried wiring with Corsair Pro XS (ASAHI) by finding a septal channel that is as thick, straight, and less tortuosity as possible. We used 014 Sion blue (ASAHI) guidewire as a workhorse wire. After reaching the septal channel entry, we exchanged to SUOH 03 (ASAHI) guidewire for septal channel tracking. After the wire passed through the channel exit, we exchanged to Ultimate Bros 3 (ASAHI) guidewire for penetrating distal CTO cap. And then, we tried to wiring by antegrade approach using 0.14 Fielder XT-A(ASAHI) wire with microcatheter. And then kissing wire cross was successfully done. Using RG3(ASAHI) wire, we performed wire externalization and then we inserted stents from proximal to distal RCA with Orsiro mission(BIOTRONIK) 3.5/30, 3.0/35mm using intravscular ultrasound(IVUS).



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This is a case of successful hronic total occlusion(CTO) percutaneous coronary intervention(PCI) in a patient with both subclavian arteries stenosis who was not suitable for coronary artery bypass graft, and a case of successful primary retrograde CTO PCI with step by step.