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TCTAP C-104 Recanalization of RCA CTO by Contemporary Reverse CART and Long-Torturous Epicardial Collaterals
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
S193
[CLINICAL INFORMATION] Patient initials or identifier number. Mr. LWY Relevant clinical history and physical exam. Mr. LWY, a 54 year-old heavy-smoker, has diabetes and hypertension for more than 6 years. He also has dyslipidemia, gouty arthritis, stage 4 CKD and 2-V CAD which was treated by PCI with DES stenting to LCX one year before admission. RCA CTO found at that time but had a failed attempt to reopen(failed to cross LAD septal branch collaterals and antegrade approach by a stiff wire resulted in coronary perforation).He still had dyspnea and LVEF was 43%. Revascularization of RCA CTO was planned. Relevant test results prior to catheterization. Echocardiography: 1. Regional wall motion abnormality with dilated LV and borderline LV systolic function, suggestive of RCA disease 2. LV grade I diastolic dysfunction Relevant catheterization findings. Prior coronary angiography: Failed attempt to use septal collateral’s last time. There’s another epicardial collateral’s from LCX, but much longer and torturous. [INTERVENTIONAL MANAGEMENT] Procedural step. Target lesion: Seg. 2-3 mid to distal RCA CTO. Approach:bi-radial artery. Catheter: 7Fr EBU 3.75 with 10 cm cutshort, engaged to LM from right radial artery; 6Fr SAL2 with side hole, engaged to RCA from left radial artery. We started from retrograde approach: a Sion wire in Corsair micro catheter was used to cross the long torturous epicardial collateral from LCX and reached RCA-PL branch. After Corsair catheter reached crux, retrograde wiring was further done by Fielder FC and UB3 wire but cannot cross the calcified spot and all went into sub intimal space. Anterograde wiring was then tried by Sion and Fielder XT wires in Pro great micro catheter but still failed. Retrograde wiring by Conquest Pro again was also failed. We tried R-CART at d-RCA by 2.5 mm balloon but cannot enter true lumen. Retrograde wiring was tried again by a new Fielder FC wire and then cross the calcified spot but may went into sub intima(however, the bi-directional wires seemed quite close to each other now). R-CART was performed again by 2.0 mm balloon at m-RCA and then retrograde wire entered the true lumen. Using a 6Fr guidelines into m-RCA to reach retrograde Corsair catheter, Rendezvous technique by retrograde wire succeed. Predilation was done by 1.5 mm mini-Trek, 2.0 mm, and 2.5 mm balloon catheter sequentially. IVUS was performed to ensure vessel size and plaque burden. After two long DES deployment and further post-dilation, good result of angiography and TIMI-3 flow were achieved.
Case Summary. The proximal tortuous route was not easier than CTO. Multiple gentle techniques were used before having a mess. Controlled damaged was important for antegrade approach. Due to the proximal tortuous part, retrograde approach would face same problem, and would not be the solution. Careful planning for approach, side-branch use, wire selection was basic, but important. This is a case looking great for trying, but actually with much difficulties. It would remind a interventionist more thoughtful, not only to the CTO lesion. TCTAP C-104 Recanalization of RCA CTO by Contemporary Reverse CART and Long-Torturous Epicardial Collaterals Ping-Han Lo,1 Ke-Wei Chen1 China Medical University Hospital, Taiwan
1
S194
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
TCTAP C-105 Step Wise of Stent Delivery After Wire Crossing CTO: Another Challenge Situation Johan Senihardja,1 Bambang Budiono,2 Benny Mulyanto Setiadi,1 Agnes Lucia Panda,1 Janry Anton Pangemanan,1 Rizki Francis Pandelaki,1 Monique Priscilla Fransiska Rotty,1 Soetandar Widjaja,1 Iman Suhartono1 1 Sam Ratulangi University Manado, Indonesia; 2Awal Bros Makassar Hospital, Indonesia [CLINICAL INFORMATION] Patient initials or identifier number. IM Relevant clinical history and physical exam. A 51 years-old male admitted with complaining chest pain for the last one week. He felt a tight sensation at his chest while doing light activity such as walking for short distance. He already received the medical therapy. Two months earlier, patient was hospitalized due to the same complaint and treated as unstable angina pectoris. He had history of hypertension for long time period. Physical examination was within normal limit. Relevant test results prior to catheterization. ECG showed that there was Q pathology at inferior lead suggesting there is old myocardium infraction at that region. Relevant catheterization findings. Diagnostic coronary angiogram showed that there were stenosis about 60% at proximal LAD, stenosis 90% at proximal LCx, chronic total occlusion (CTO) at mid LCx. For RCA, there was ostial lesion and CTO from proximal RCA. [INTERVENTIONAL MANAGEMENT] Procedural step. PCI to RCA was done using trans radial technique. A 6 Fr TR 4.0 guide catheter was inserted to engage ostial right coronary. A 0.014“ Runthrough Hypercoat wire was inserted into RCA. After successful crossing, the lesion, a 2.0 x 20 mm Maverick balloon was used to pre-dilate the proximal to mid RCA at 6 atm. After serial predilatation, there was a difficulty in advancing 3,0 x 38 mm CRE8 stent through the lesion. Not just once, but a second attempt still failed. Another 0.014” Run through hyper coat wire was inserted for side branch anchoring technique. Additional pre-dilatation was then performed, but the stent still remained unable to cross the lesion. The side wire anchoring was removed and then was advanced to the distal RCA as buddy wire. This attempt was failed to deliver stent. Eventually, the operator chose to try distal anchoring balloon to overcome the difficulty. While stent was positioned at tip of the catheter, a 2.0 x 20 mm Maverick balloon was advanced to distal RCA and inflated at 4 atm. Re-advanced the stent was successful, and then distal balloon was deflated and removed. The lesion was treated with 3.0 x 38 mm CRE8 stent. The final angiographic result was very good with TIMI 3 Flow.
Case Summary. In this case, long and torturous epicardial collateral’s impaired torque ability of wires and made retrograde approach more difficult. Carefully advance of proper micro catheter helps to control wire and saves contrast. Reverse CART technique is useful to achieve true lumen while bi-directional wire goes close to each other in sub intimal space.
S193
[CLINICAL INFORMATION] Patient initials or identifier number. Mr. LWY Relevant clinical history and physical exam. Mr. LWY, a 54 year-old heavy-smoker, has diabetes and hypertension for more than 6 years. He also has dyslipidemia, gouty arthritis, stage 4 CKD and 2-V CAD which was treated by PCI with DES stenting to LCX one year before admission. RCA CTO found at that time but had a failed attempt to reopen(failed to cross LAD septal branch collaterals and antegrade approach by a stiff wire resulted in coronary perforation).He still had dyspnea and LVEF was 43%. Revascularization of RCA CTO was planned. Relevant test results prior to catheterization. Echocardiography: 1. Regional wall motion abnormality with dilated LV and borderline LV systolic function, suggestive of RCA disease 2. LV grade I diastolic dysfunction Relevant catheterization findings. Prior coronary angiography: Failed attempt to use septal collateral’s last time. There’s another epicardial collateral’s from LCX, but much longer and torturous. [INTERVENTIONAL MANAGEMENT] Procedural step. Target lesion: Seg. 2-3 mid to distal RCA CTO. Approach:bi-radial artery. Catheter: 7Fr EBU 3.75 with 10 cm cutshort, engaged to LM from right radial artery; 6Fr SAL2 with side hole, engaged to RCA from left radial artery. We started from retrograde approach: a Sion wire in Corsair micro catheter was used to cross the long torturous epicardial collateral from LCX and reached RCA-PL branch. After Corsair catheter reached crux, retrograde wiring was further done by Fielder FC and UB3 wire but cannot cross the calcified spot and all went into sub intimal space. Anterograde wiring was then tried by Sion and Fielder XT wires in Pro great micro catheter but still failed. Retrograde wiring by Conquest Pro again was also failed. We tried R-CART at d-RCA by 2.5 mm balloon but cannot enter true lumen. Retrograde wiring was tried again by a new Fielder FC wire and then cross the calcified spot but may went into sub intima(however, the bi-directional wires seemed quite close to each other now). R-CART was performed again by 2.0 mm balloon at m-RCA and then retrograde wire entered the true lumen. Using a 6Fr guidelines into m-RCA to reach retrograde Corsair catheter, Rendezvous technique by retrograde wire succeed. Predilation was done by 1.5 mm mini-Trek, 2.0 mm, and 2.5 mm balloon catheter sequentially. IVUS was performed to ensure vessel size and plaque burden. After two long DES deployment and further post-dilation, good result of angiography and TIMI-3 flow were achieved.
Case Summary. The proximal tortuous route was not easier than CTO. Multiple gentle techniques were used before having a mess. Controlled damaged was important for antegrade approach. Due to the proximal tortuous part, retrograde approach would face same problem, and would not be the solution. Careful planning for approach, side-branch use, wire selection was basic, but important. This is a case looking great for trying, but actually with much difficulties. It would remind a interventionist more thoughtful, not only to the CTO lesion. TCTAP C-104 Recanalization of RCA CTO by Contemporary Reverse CART and Long-Torturous Epicardial Collaterals Ping-Han Lo,1 Ke-Wei Chen1 China Medical University Hospital, Taiwan
1
S194
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
TCTAP C-105 Step Wise of Stent Delivery After Wire Crossing CTO: Another Challenge Situation Johan Senihardja,1 Bambang Budiono,2 Benny Mulyanto Setiadi,1 Agnes Lucia Panda,1 Janry Anton Pangemanan,1 Rizki Francis Pandelaki,1 Monique Priscilla Fransiska Rotty,1 Soetandar Widjaja,1 Iman Suhartono1 1 Sam Ratulangi University Manado, Indonesia; 2Awal Bros Makassar Hospital, Indonesia [CLINICAL INFORMATION] Patient initials or identifier number. IM Relevant clinical history and physical exam. A 51 years-old male admitted with complaining chest pain for the last one week. He felt a tight sensation at his chest while doing light activity such as walking for short distance. He already received the medical therapy. Two months earlier, patient was hospitalized due to the same complaint and treated as unstable angina pectoris. He had history of hypertension for long time period. Physical examination was within normal limit. Relevant test results prior to catheterization. ECG showed that there was Q pathology at inferior lead suggesting there is old myocardium infraction at that region. Relevant catheterization findings. Diagnostic coronary angiogram showed that there were stenosis about 60% at proximal LAD, stenosis 90% at proximal LCx, chronic total occlusion (CTO) at mid LCx. For RCA, there was ostial lesion and CTO from proximal RCA. [INTERVENTIONAL MANAGEMENT] Procedural step. PCI to RCA was done using trans radial technique. A 6 Fr TR 4.0 guide catheter was inserted to engage ostial right coronary. A 0.014“ Runthrough Hypercoat wire was inserted into RCA. After successful crossing, the lesion, a 2.0 x 20 mm Maverick balloon was used to pre-dilate the proximal to mid RCA at 6 atm. After serial predilatation, there was a difficulty in advancing 3,0 x 38 mm CRE8 stent through the lesion. Not just once, but a second attempt still failed. Another 0.014” Run through hyper coat wire was inserted for side branch anchoring technique. Additional pre-dilatation was then performed, but the stent still remained unable to cross the lesion. The side wire anchoring was removed and then was advanced to the distal RCA as buddy wire. This attempt was failed to deliver stent. Eventually, the operator chose to try distal anchoring balloon to overcome the difficulty. While stent was positioned at tip of the catheter, a 2.0 x 20 mm Maverick balloon was advanced to distal RCA and inflated at 4 atm. Re-advanced the stent was successful, and then distal balloon was deflated and removed. The lesion was treated with 3.0 x 38 mm CRE8 stent. The final angiographic result was very good with TIMI 3 Flow.
Case Summary. In this case, long and torturous epicardial collateral’s impaired torque ability of wires and made retrograde approach more difficult. Carefully advance of proper micro catheter helps to control wire and saves contrast. Reverse CART technique is useful to achieve true lumen while bi-directional wire goes close to each other in sub intimal space.