Antegrade approach for mLAD CTO

- Operator : Etsuo Tsuchikane

Antegrade approach for mLAD CTO

- Operator: Etsuo Tsuchikane, MD

Case Presentation

A 39 year old gentleman was admitted with stable angina pectoris. He had a past history of failed PCI at proximal LAD in another hospital one year ago. His coronary risk factor was hyperlipidemia. The echocardiography showed normal LV systolic function without RWMA (EF=58%). TMT was positive at stage 4 and thallium scan showed partially reversible large sized perfusion defect at LAD territory.

Baseline coronary angiography

The left coronary angiogram showed total occlusion of mLAD ( Movie 1). The right coronary angiogram was normal ( Movie 2) and collateral flow from RCA to LAD was noted ( Movie 3, Movie 4).

Procedure

An 8 Fr long sheath was inserted through left femoral artery and a 7 Fr sheath was inserted through right femoral artery. The left and right coronary artery ostium were engaged with an 8 Fr XB 3.5 guiding catheter and a 7 Fr JR4 guiding catheter, respectively. First, we engaged Rinato 0.014 inch - 180cm wire into the first diagonal branch (Figure 1). We checked the IVUS to find the exact entry point at mLAD. After that, we tried antegrade approach at mLAD by using a Ultimate 3 0.014 inch – 180 cm wire with a Corsair® 0.014 inch 2.6 Fr -135 cm Coronary Micro-Guide catheter and succeeded in the engagement of the wire into the second diagonal branch ( Movie 5). We replaced the Cosair® Coronary Micro-Guide catheter with Crusade micro-catheter at pLAD and succeeded to cross the mLAD CTO lesion by using SION 0.014 inch – 180cm wire (Figure 2). Predilatation was performed with Ikazuchi 2.0 x 15mm balloon and Sprinter Legend 2.0 x 15mm balloon at mLAD (Figure 3). Resolute integrity stent 2.75 x 30mm was implanted at pmLAD (Figure 4). We performed post-stent dilatation by using Nimbus Salvo 3.5 x 13 mm balloon (Figure 5). The following coronary angiogram showed well expanded stents at pmRCA ( Movie 6, Movie 7).