Antegrade Approach for pLAD CTO

- Operator : Seung-Whan Lee

Antegrade Approach for pLAD CTO
- Operator: Seung-Whan Lee, MD
Case Presentation
A 65-year-old woman was admitted with effort chest pain for several years. Nine years ago, she had experienced an anterior wall STEMI, and was treated medically. One year ago, she underwent PCI at RCA in other hospital. Her coronary risk factors were hypertension, hyperlipidemia and ex-smoking. The echocardiography showed LAD territory RWMA with mild LV dysfunction (EF=47%). TMT was positive at stage 2 and thallium scan showed partially reversible large sized perfusion defect at LAD territory.
Baseline coronary angiogram
The left coronary angiogram showed total occlusion at pLAD ( Movie 1, Movie 2, Movie 3) and the right coronary angiogram showed patent previous stents at pmRCA and dRCA, but stent fracure was noted at mRCA.
An 8 Fr sheath was inserted through right femoral artery, and the left coronary artery ostium was engaged with an 8 Fr XB 3.0 catheter with side hole. Initially, we inserted a BMW 0.014-inch 190cm guidewire into LAD- septal branch (Figure 1). Because of severe angulation of LAD , IVUS catheter could not be inserted to evaluation of lesion(Figure 2). Then, we tried to insert guide –wire into LAD with Fielder FC 0.014 inch 175cm guide wire with a Corsair¢ē 0.014 inch 2.6 Fr – 150 cm microcatheter. We failed several times for guide wire to pass into the LAD. Finally, by using anchoring with Amadeus 2.5-15mm, 0.014 inch Fielder FC 180cm guide was inserted LAD (Figure 3). After that, wire was exchanged to 0.014 BMW guide wire(Figure 4). Predilatation was performed with a 1.5 x 15mm IKAZUCHI balloon at pLAD(Figure 5). After IVUS examination and predilatation with Amadeus 2.5x 15mm(Figure 6), two drug eluting stents were deployed (XIENCE PRIME 2.5 x 38 mm at mLAD, XIENCE prime 3.5 x 28 mm at pmLAD)(Figure 7). After IVUS examination, post-stenting adjunctive balloon dilatation was done by using a 3.0 x 17mm Nimbus Salvo balloon(Figure 8). The following coronary angiogram showed well-expanded ( Movie 4).

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