Case 271: Manual of CTO PCI - Challenging access

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A patient with morbid obesity and known CTO of the right coronary artery presented with dyspnea and was found to have a new CTO of the mid circumflex. He was referred for PCI of the circumflex CTO. Right heart catheterization was attempted prior to PCI due to concerns for congestive heart failure via an antecubital vein. Delivery of a 6 French Swan Ganz catheter was challenging but eventually successful after using a 0.014 inch workhorse wire. Engagement of the left main was also challenging due to subclavian tortuosity but was eventually successful after using a 85 cm long R2P sheath (this was only available in 6 French, hence a 6 French guide catheter was used). The circumflex CTO was short (̴10 mm) with a clear proximal cap and no calcification. It was wired easily with Gaia 1st wire. After exchange for a workhorse wire a Sapphire balloon was advanced to the CTO but visualization was poor and the balloon advanced too distally and became entrapped. After multiple attempts the balloon was retrieved, fortunately without vessel injury and without losing wire position. The lesion was predilated and stented with an excellent final result.
Category
Cardiology
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