Recanalization of an old and long complex RCA

Recanalization of an old and long complex RCA CTO AR Galassi, MD, FACC, FESC, FSCAI Head of Cardiac Catheterization and Interventional Cardiology Unit, Division of Cardiology, Ferrarotto Hospital Associate Professor of Cardiology University of Catania, ITALY

CASE SUMMARY

In 2004……. 7 years after CABG…… Native LCA Patient underwent 1 BMS on D 1

In 2004……. 7 years after CABG…… Native RCA

In 2004……. 7 years after CABG…… LIMA on LAD

In 2004……. 7 years after CABG…… Slow flow of RIMA (functionally occluded)

In 2004……. 7 years after CABG…… LV Angio

…despite BMS on D 1, angina CCS II, and in 2007…. CTO of distal RIMA attempt

…despite BMS on D 1, angina CCS II, and in 2007…. CTO of distal RIMA attempt

2007 PCI with DES of RIMA (full metal jacket) PCI of RIMA with 3 BMS + 1 DES

Asymptomatic until 11 -2009 when she had angina CCS II, worsening to CCS III in 2010 LIMA on LAD

Asymptomatic until 11 -2009 when she had angina CCS II, worsening to CCS III in 2010 Native RCA-CTO with ipsi and contra -lateral filling

Asymptomatic until 11 -2009 when she had angina CCS II, worsening to CCS III in 2010 Reocclusion of RIMA

Asymptomatic until 11 -2009 when she had angina CCS II, worsening to CCS III in 2010 LV Angio

Step. Down/Step. Up Technique LAO projection Confianza Pro (Abbott-Asahi) Finecross Microcatheter (Terumo)

Step. Down/Step. Up Technique RAO projection Confianza Pro (Abbott-Asahi) Finecross Microcatheter (Terumo)

Step. Down/Step. Up Technique AP cranial projection Confianza Pro (Abbott-Asahi) Finecross Microcatheter (Terumo)

Step. Down/Step. Up Technique LAO projection Confianza Pro (Abbott-Asahi) Finecross Microcatheter (Terumo)

Step. Up/Step. Down Technique AP cranial projection Fielder FC (Abbott-Asahi) Finecross Microcatheter (Terumo)

Step. Up/Step. Down Technique AP cranial projection Fielder FC (Abbott-Asahi) Finecross Microcatheter (Terumo)

Step. Up/Step. Down Technique OAD projection Fielder FC (Abbott-Asahi) Finecross Microcatheter (Terumo)

Step. Up/Step. Down Technique AP cranial projection Fielder FC (Abbott-Asahi) Finecross Microcatheter (Terumo)

Parallel Wire Technique OAD projection 2 Conquest pro (Abbott-Asahi)

Parallel Wire Technique AP cranial projection 2 Conquest pro (Abbott-Asahi)

Parallel wire technique OAD projection 2 Conquest pro (Abbott-Asahi)

Parallel wire technique AP cranial projection 2 Conquest pro (Abbott-Asahi)

Parallel wire technique OAD projection Conquest pro (Abbott-Asahi) Fielder FC (Abbott-Asahi)

STAR from proximal origin of RCA Fielder FC (Abbott-Asahi) Finecross Microcatheter (Terumo) Conquest pro (Abbott-Asahi) 1. 53 min

New Fielder guidewire pathway

STAR guidewire from subintima reenter into true vessel Pilot 50 (Abbott) Finecross Microcatheter (Terumo) Conquest pro (Abbott-Asahi) 1. 53 min

Balloon dilatation CID 1. 1 x 10 mm Acrostak

Balloon dilatation Minitrek 1. 20 x 15 mm Abbott

Balloon dilatation Minitrek 2. 00 x 20 mm Abbott

Balloon dilatation Minitrek 2. 0 x 20 mm Abbott

Balloon dilatation Minitrek 2. 0 x 20 mm Abbott

Sequential balloon dilatation Minitrek 2. 0 x 20 mm Abbott

Sequential balloon dilatation Minitrek 2. 0 x 20 mm Abbott

Sequential balloon dilatation Minitrek 2. 0 x 20 mm Abbott

Sequential balloon dilatation Minitrek 2. 0 x 20 mm Abbott

Tip microcatheter injection in distal RCA Finecross Microcatheter (Terumo)

Balloon dilatation Minitrek 2. 5 x 20 mm Abbott

Balloon dilatation Minitrek 2. 5 x 20 mm Abbott

IVUS in RCA 0. 40 min

Coronary vessel rupture

Proximal balloon dilatation to prevent futher bleeding

4 SES implantations

Final result

Final result

Final result

Take Home Message • Atherosclerosis may progress in native artery and arterial grafts and patients might be refused from surgeons for redo • Left internal mammary artery stenting is generally better to avoid as restenosis especially with BMS is very likely to occur in a short time frame of window • es • In case of unsuitable collateral circulation, an antegrade approach might be attempt even in a CTO 13 years old • The STAR (Subintimal Tracking And Reentry) technique by the use of a soft polymeric guidewire with an auto-J shaping wiring mode might help to redirect the wire towards the true lumen direction even if subintimally • Percutaneous CTO revascularization might determines a significant relief of angina, being associated with more favourable outcome at follow-up (since the procedure the patient is now completely asymptomatic)

Take home message It must be hard without ever losing tenderness