Retrograde Approach for Distal RCA CTO Lesion through the Septal Branch

- Operator : Seung-Whan Lee

Retrograde Approach for Distal RCA CTO Lesion through the Septal Branch

- Operator: Seung-Whan Lee, MD

Case Presentation

A 43 years-old gentleman was admitted for intermittent palpitation combined with chest pain for several days. His coronary risk factor was hypertension and ex-smoker. He had diagnosed with coronary artery disease at 2 years ago at other hospital, but PCI was failed at that time. He had continued on medical treatment since then. In this time, as large amount of reversible myocardium was found in the thallium scan, we decided to revascularize his coronary artery. The initial attempt of anterograde approach was failed in other hospital, we decided to re-attempt the RCA-CTO by retrograde approach.

Baseline Coronary Angiogram

Left coronary angiogram showed mild coronary artery disease of LAD and LCX, and previous stent in the Di branch was found to be patent. It also showed collateral flow from septal branches of LAD to RCA ( Movie 1). The right coronary angiogram showed total occlusion of RCA from its proximal portion with grade 3 bridging collateral flow.( Movie 2).

Procedure

Right coronary artery was engaged with a 7 Fr XB 3.5 guiding catheter and left coronary artery was positioned with a 7 Fr JR4 SH guiding catheter through the bi-femoral approach. We tried to reach the distal cap of the CTO lesion through several septal braches using Fielder FC, XT, XT-A wires with Cosair® 150cm microcatheter. After several trials, we barely found the optimal septal brach (Figure 1). We tried to pass the proximal RCA-CTO lesion with a 0.014 inch Gaia 2 wire, but also failed ( Movie 3). So, we changed wire into 0.014 inch Ultimate 3 wire and successfully penetrated the proximal cap ( Movie 4). After advancement of Corsair® microcatheter into the right guiding catheter, a retrograde wire was exchanged for a 0.010 inch RG3 wire. And then we performed several balloon dilatations at proximal to distal RCA using a Maverick balloon 1.5x20mm and 2.5x15mm (Figure 2). After predilatations, we deployed a three Xience Xpedition stents (3.0x38mm, 3.5x38mm, and 4.0x23mm, distal to proximal RCA, Figure 3) sequentially. The final angiogram showed successful revascularization at RCA CTO lesion ( Movie 5).