E-SCIENCE STATION

CASE20230618_001

A Case of Retrograde CTO PCI

By Gajendra Dubey, Karthik Natarajan

Presenter

Karthik Natarajan Karthik Natarajan

Authors

Gajendra Dubey1, Karthik Natarajan2

Affiliation

U N MEHTA INSTITUTE OF CARDIOLOGY AND RESEARCH CENTRE AHMEDABAD, India1, U N Mehta Institute of Cardiology & Research Centre, India2,
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CASE20230618_001
Complex PCI - CTO

A Case of Retrograde CTO PCI

Gajendra Dubey1, Karthik Natarajan2

U N MEHTA INSTITUTE OF CARDIOLOGY AND RESEARCH CENTRE AHMEDABAD, India1, U N Mehta Institute of Cardiology & Research Centre, India2,

Clinical Information

Relevant Clinical History and Physical Exam

61 year old male patient named Mr U S. 
Hypertension(5 years), Dyslipidemia( 5 years). 
History of Inferior wall Myocardial Infarction 6 moths back. CAG done at outside hospital. Attempted PCI to RCA 2 months back(failed). 
Current complaints- CCS-3 angina
Physical examination- Unremarkable



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Relevant Test Results Prior to Catheterization


Blood Investigations- Unremarkable
ECG- q waves in 2, 3, avF
Echo- EF-45% with RCA territory hypokinesia with preserved wall thickness

Relevant Catheterization Findings

CAG showed totally occluded RCA and OM branches. There were epicardial collaterals from LCX to RCA. There were no visible septal collaterals from LAD to RCA.
Target Vessel – RCA(J-CTO-2)Access- Right Femoral- 7F AL1. Right Radial- 6F EBUStrategy- 1) AWE                                        2) Retrograde via possible  septal collateral from LAD                3) Retrograde via epicardial collateral from LCX 

Interventional Management

Procedural Step


Safety wire in LAD. AL-1 caused staining at ostium of RCA. Switched to JR4 and put workhorse wire in RCA. Avoid antegrade injections. Started off with Fielder XT-A and finercross microcatheter but failed. Switched to Gaia 3 and made some progress. Penetrated distal cap with CP12 which went exrtraplaque. Parallel wiring failed. Decided on retrograde. No good septal collaterals. Went through epicardial collateral with finecross and suoh 3. Reached Distal RCA. Tried RWE with Gaia 3 but failed. Did Contemporary reverse cart with 2.5 mm NC balloon. Negotiated Gaia 3rd into antegrade guide. Microcatherer would not follow. Did multiple balloon dilations in proximal RCA. Finally finecross reached antegrade guide. Extrenalisation with RG3. Antegrade injection created large aorto-coronary dissection. Proximal RCA stenosis remained balloon undilatable. Did Rotablation with 1.5 mm burr but still remained undilatable. Grenadoplasty with 3.5 mm balloon. Lesion opened up. 3 overlapping DES from ostium to distal RCA under IVUS guidance. Final Angiographic and IVUS results satisfactory.·       
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Case Summary

•CTO PCI requires meticulousplanning and knowledge of hardware

•Familiarity with use of Antegradeand Retrograde approach increases the success of CTO PCI

•Calcium modifying tools are a must have in balloon uncrossable and balloon undilatable lesions

•Imaging helps in improving longterm success of CTO PCI