Case 274: Manual of CTO PCI - Entrapment x2

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A patient with right coronary artery (RCA) and circumflex CTOs was referred for PCI of the RCA CTO after being turned down for CABG. The RCA CTO had an ambiguous proximal cap at the takeoff of an acute marginal branch, length of approximately 30 mm, and diffusely diseased distal vessel that was filling via both septal and epicardial collaterals from the LAD. Given proximal cap ambiguity a primary retrograde approach was selected. A Suoh 03 did not cross but a Sion black successfully crossed into the right posterolateral and eventually to the distal RCA. A knuckled Mongo wire was advanced retrogradely all the way to the proximal cap, resolving the ambiguity. Using a Gaia Next 2 wire, guide extension reverse CART with the DRAFT technique (Deflate, Retract and Advance into the Fenestration). The antegrade balloon became entangled with the retrograde Caravel microcatheter. Eventually the tip of the Caravel broke off and came out over the antegrade balloon. An HD IVUS catheter was advanced through the 6 Fr guide extension over the externalized R350 wire and also became entrapped, requiring retrieval of both the IVUS and the R350 en bloc. A new R350 was inserted, followed by successful balloon angioplasty and stenting with a nice final result.
Category
Cardiology
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