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
Angiogram
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
STEPS
- 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)
STEPS
- 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.
STEPS
- 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
STEPS
- 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).
