XYZ

65/fNon HTN/Non DMpresented wit IWMI one year back angain acute IWMI 2 months back. She was thrombolysed with STK at other centerThen she was refeed for CAG and further management to our centerHer blood investigations were normalECG showed evolved IWMI

CAGperformed through Rt Radial showedLAD-- NormalLcx-- Non Dominant, NormalRCA-- Dominant, Proxoaml CTO, distal faintly filled viaLCA 

CAG showed SVD

Access: Rt Femoral Artery6F femoral sheathGuide: 6F JR, 0.75 ALWires: CROSS IT 100          Runthrough FloppyBalloons: 1.5x 8, 2 x 8, 2.5 x 8 NC
Procedure:RCA was initailly tried to engage with JR but was not able to canulate so swiched to 0.75 ALLesion was crossed with CROSS IT 100 beyond the lesion , dottered with 1.5 x 8 and predialted multiple times at high pressure. Then predialted with 2x 8 at high pressure. But was not able to see distal vesselIt was dilated again beyond bend with 2x 8 up t0 16 atm.Then one stent 2.75 x 28 SES was implanted proximally at 14 atm. but distal vessel could not be seen. then 2.5 x8 NC balloon was taken more distall   and dialated at 10 atm. At this time distal vessel was seen,Another 2.5 x 44 SES overlapping first stent was implanted at 12atm, Post dilated with 3 x8 upto a4 atmFinal result was excellent with TIMI III flow, no dissection and no slow flow.

Take Home Message:CTO is always challenging caseCorrect guide and wire will increase success rateIn this case It was difficult to decide whether I was entering subintimally or its a thrombus. I was not able to see distal vessel even after implantation of first stentFinally patients and perseverance pays