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 44 year-old male patient was admitted for decreased left ventricular ejection fraction on echocardiography combined with chest pain for several months. His coronary risk factor was hypertension and hyperlipidemia. He had previous history of NSTEMI and underwent PCI at LAD and LCX from other hospital 8 months ago. There was CTO lesion also at proximal RCA but PCI was failed at that time. He had continued on medical treatment since then. In this time, the left ventricular systolic function was decreased steadily, we decided to re-vascularize his coronary artery. As 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
  1. Left coronary angiogram showed mild coronary artery disease of LAD and LCX, and previous stents in the LAD and LCX-OM branch were found to be patent. It also showed collateral flow from septal branches of LAD to RCA ( Movie 1).
  2. The right coronary angiogram showed total occlusion of RCA from its proximal portion ( Movie 2).
Procedure
Right coronary artery was engaged with an 8 Fr SAL 1.5 guiding catheter and left coronary artery was positioned with a 7 Fr XB 4 guiding catheter through the bi-femoral approach. We tried to reach the distal cap of the CTO lesion through several septal braches using Fielder XT, Gaia3, Sion black, RG3 wires with Corsair¢ç 150cm microcatheter. After several trials, we barely found the optimal septal branch (Figure 1). We tried to pass the proximal RCA-CTO lesion with a 0.014 inch Gaia3 wire and successfully penetrated the proximal cap ( Movie 3). After advancement of Corsair¢ç 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 Maverick balloon 2.5x15mm and IKAZUCHI 2.0x20mm (Figure 2). After predilatations, we deployed four Xience Alpine stents (2.5x38mm, 3.0x38mm, 3.5x38mm and 4.0x18mm, distal to proximal RCA, Figure 3, Figure 4, Figure 5, Figure 6) sequentially. The final angiogram showed successful revascularization at RCA CTO lesion ( Movie 4).

Comments

  • Surenjav Chimed 2017-01-02 Excellent case. I have one question. Why did exchange retrograde Gaia3 wire by RG3 wire? Thank you.
  • Se Hun Kang 2017-01-02 Thank you for your comments. It was not described exactly, we usually use Gaia 3rd with 190 cm. In this case, we also used Gaia 3rd with 190 cm. Therefore we have to exchange Gaia 3rd wire with RG3 330 cm wire, after penetration of proximal cap with retrograde approach.

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