E-Science Station

Complex PCI - Chronic Total Occlusion
Intra-coronary Rendezvous Technique with RG3 for an RCA CTO with Un-crossable Retrograde Micro-catheter
Cheng-Chun Wei1
Shin Kong Memorial Hospital, Taiwan1,
[Clinical Information]
- Patient initials or identifier number:
-Relevant clinical history and physical exam:
A 64 y/o man suffered from unstable angina 3 months ago and underwent LAD PCI with DES. At that time, RCA PDA total occlusion was found and the operator tried to open it but failed. (failed to puncture the entry and the retrograde wiring made perforation) His past history included hypertension, diabetes, and hyperlipidemia. The patient still suffered from effort angina and Thallium scan showed severe inferior wall ischemia, so we decided to open the occluded RCA PDA CTO.
-Relevant test results prior to catheterization:
Thallium scan showed large inferior wall ischemia extent. Cardiac echo also showed inferior wall hypokinesis but the thickness of inferior wall was preserved. Previous CAG about 6 months ago showed RCA PDA total occlusion with collaterals from septal channels. The territory of PDA perfusion was large through angiographic evaluation. 

- Relevant catheterization findings:
The entry of RCA PDA CTO was ambiguous. The body of CTO was filled with calcification which was a good landmark for wiring. The length of PDA CTO was about 3 cm. The J-CTO score was 4 (one for entry, one for length >2cm, one for retry, and one for calcification).
LAD with good septal collateral to the RCA PDA. Previous LAD stent did not involve the major septal collateral to PDA.

[Interventional Management]
- Procedural step:
We approached from bilateral femoral artery with 8Fr AL1 for RCA and 7Fr EBU for LCA. We started from antegrade approach with IVUS guidance. XTA was used for entry puncture initially. However, due to hevay calcification at the entry, we shifted to Gaia 1-->Gaia 2-->Gaia 3. Wire de-escalated to UB3 after Gaia 3 advanced into the CTO body. We manipulated the UB3 in accordance to the shadow of calcification and we finished the antegrade preparation after UB3 went into subintimal space. 
We then shifted to retrograde approach from LAD septal channel. Under the support of Caravel, SUHO 03 crossed the bend part of septal and went into the PDA. The tip injection showed the blunt morphology of PDA CTO exit. We attacked the exit with XTA first. The wire easily deviated from the direction of correct route. Wire was escalated to Gaia 3. After some efforts, we made antegrade and retrograde wire overlapped each other. Guide-extention rCART was performed and Gaia 3 went into AGC. Under the balloon trapping in the AGC, we tried to pushed the RMC into AGC but failed. The MC stuck inside the CTO body with heavy calcification. We tried rendezvous technique in AGC but the AMC failed to cross the calcified point in the CTO, too. Then, we tried to place both AMC and RMC as close to each other as possible, and changed the RGW to RG3 and successfully controlled the RG3 into AMC. After extenalization, balloon angioplasty-->1.25mm RA-->balloon angioplasty-->DES stenting were done well.
- Case Summary:
Intra-coronary RG3 rendezvous is a special technique for retrograde micro-catheter failure to advance into the antegrade guiding catheter. The space created by retrograde wire is always large enough for RG3 to cross. Before withdrawing the retrograde wire, we have to 1. make both side micro-catheter as close to each other as possible 2. make a relatively small bend at the tip of RG3 3. try to rendezvous at a horizontal plane. This technique should be the last resort when you try other methods to pass your retrograde micro-catheter because you always take some risks to lose your wire in CTO if you fail.  
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