Retrograde Approach for ISR Total Occlusion at pLAD

- Operator : Etsuo Tsuchikane

Retrograde Approach for ISR Total Occlusion at pLAD

- Operator: Etsuo Tsuchikane, MD

Case Presentation

A 50-year-old woman was admitted with stable angina pectoris. Two years ago, she underwent PCI at proximal LAD and mid LAD with two Everolimus-eluting stents (Promus). Three months ago, she experienced ISR at mid LAD, but PCI was failed at other hospital. Her coronary risk factors were hypertension and hyperlipidemia. The echocardiography showed LAD territory RWMA with near normal LV systolic function (EF=52%).TMT was positive at stage 3 and thallium scan showed partially reversible large sized perfusion defect at LAD territory.

Baseline coronary angiography

A left coronary angiogram showed ISR total occlusion with TIMI flow 0 at proximal LAD ( Movie 1) and a right coronary angiogram showed normal coronary finding with collateral from RCA to LAD ( Movie 2).

Procedure

Right coronary artery was cannulated with a 8 Fr ALJ1 SH guiding catheter and left coronary artery was positioned with 7 Fr JL 3.5 SH guiding catheter through the bi-femoral approach, respectively. Initially, Sion blue® 0.014 inch 180cm guidewire was inserted into LCX. And then by using the Corsair® 0.014 inch 2.6 Fr 150cm microcatheter, Sion blue® 0.014 inch 180cm guidewire was tried into PDA to the septal branch (Figure 1). Finally, we crossed the septal branch with XT-R 0.014 inch 180cm and Ultimate 0.014 inch 180cm (Figure 2). Thereafter retrograde wire was advanced into LAD guiding catheter and ASAHI Corsair ® 0.014 inch 2.8 Fr -150cm Coronary Micro-Guide catheter was advanced into LAD guiding catheter by anchoring with Amadeus 2.5 sized balloon. Retrograde wire was changed into RG3 long wire (330 cm) and externalized into outside of antegrade guiding catheter. And then Crusade ® 0.014 inch 2.6 Fr -135cm Coronary Micro-Guide catheter was advanced into LAD (Figure 3). After several predilation, we deployed 2 consecutive stents with overlapping (RESOLUTE INTEGRITY stent 3.0x24 mm and 3.0x38 mm in LM to mLAD) (Figure 4, Figure 5). Final angiogram showed successful stent expansion without periprocedural complications ( Movie 3, Movie 4).