Blunt and tortuous RCA CTO

This month, we highlight the step by step approach of a tortuous RCA CTO lesion in a 71 years old male patient, s/p LAD stenting with ischemia at the level of the anterior and inferior walls on myocardial scintigraphy. The RCA shows a 20 mm calcified occlusion at the proximal level, with a relatively tapered proximal cap and retrograde filling from the septals.

Educational Objectives

• Plan a step-by-step approach procedure for CTO lesions.
• Antegrade wire escalation.
• Access sites and size possibilities during procedure.
• Wires to favor/avoid during subintimal space manipulation.
• IVUS role in CTO.

Step-by-step procedure:

1) Access site:

• Right radial approach: 7 French EBU to the left main + workhorse wire towards the distal LAD.
• Right femoral approach: 8 French AL to the RCA.

2) Step by step approach:

• The initial strategy was antegrade wire escalation.
• Using a Corsair Pro microcatheter a Fielder XT-R wire made progress through the CTO body advancing it further with the help of a retrograde injection.
• The wire appeared to be within the vessel architecture nonetheless following a deflecting trajectory.
• Escalation of the wire for a Gaia Second that finds a better position but was still subintimal.
• Redirecting the Gaia Second towards the intraluminal space followed by microcatheter advancement.
• De-escalation back to the Fielder XT-R that finds the intraluminal space.
• Exchange of the Fielder XT-R for a Sion blue wire followed by trapping and retrieving of microcatheter.
• Pre-dilatation of the occlusion body by a 3.0 mm balloon was performed.
• Stenting of the ostial RCA using 3.5x48 mm stent was followed by intravascular ultrasound (IVUS) which confirmed a long subintimal path after the distal edge of the stent with a typical image of an extraplaque path with a well apposed stent proximally.
• Additional stenting at the extraplaque level using a 3.5x20 mm stent was performed.
• The final angiographic end-result showed a satisfactory result.

Bibliography