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Case 10: RCA CTO (Antegrade Approach)

Case Presentation

  • A 62-year-old man presented with angina chest pain for a few days. Stress MPI showed moderate infero-lateral and apical ischemia.
  • LHC showed 3V CAD (calcified long CTO of mid RCA with bridging collaterals and collaterals from LAD/LCx, 95% proximal LAD, and 90% prox LCx). Syntax score 28 and LVEF 60%.
  • After Heart team discussion, patient opted for mutivessels staged PCI. He underwent successful DES PCI of pLCA and pLCx.
  • Medical History: HTN, HLD, NIDDM, FH+
  • Medications: ASA 81mg, Ticagrelor 90mg, Metoprolol XL 50mg, Atorvastatin 40 mg, fenofibrate 145 mg, Isosorbide Mononitrate 60mg, Metformin XL 1G, Empagliflozin 10mg


Description and Planning

PCI Strategy

  • CTO length ~ 20 mm, taper proximal cap
  • Bridging Collaterals ++
  • 6F IM guide catheter
  • AWE (Fielder/Caravel microcatheter > Gaia 3 > Confianza Pro)
  • If the antegrade failed, would consider a retrograde approach


  • Since there was a small branch near the proximal cap, Fielder went to the branch during wire advancement.
  • AWE done using Gaia 3 which inadvertently went to acute marginal branch.
  • Then, Confianza 9 with Micro14 catheter was changed.
  • Since the guide catheter didn’t provide enough support, decided to exchange to AL 0.75 guide catheter.

AWE (Fielder > Gaia)


  • The Confianza 9 was successfully negotiated to the distal RCA.
  • Since we couldn’t advance the microcatheter, planned to use balloon trapping technique to remove the microcatheter.


  • For 6F guide catheter, we used 2.5 balloon(14 atm) to trap the wire at distal end and removed the microcatheter.

Wiring And Balloon Trapping Technique


  • After removal of microcatheter, we used a guide catheter extension (Guidezilla in this case).
  • First, semicompliant balloon 1.2/6 mm was used, followed by NC 2.0/20 balloon dilatation.
  • One DES (Xience 3/38) was placed in RCA with an excellent result.

    The case can be reviewed at https://ccclivecases.org/july-2018-ccc-live-case

Final Angiogram

Learning Points

  • Pre-procedural planning is vital in CTO intervention along with planned AWE. Confianza Pro 9 crossed the CTO segment in this case.
  • If Gaia wire goes into subintimal space, we would strongly suggest to pull back and re-enter from a different entry point using a different wire. Here, we used Confianza wire.
  • If a microcatheter could not advance after wire crossed, consider to use balloon trapping technique to remove the microcatheter, followed by a serial balloon dilatation (starting from 1.0 > 1.2 > 1.5 > 2.0 mm).

Left Main DK Crush Video ID