Case 275: Manual of CTO PCI - Sequential troubleshooting

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A patient with prior coronary bypass graft surgery presented with severe angina and was found to have occlusion of the native RCA as well as the SVG-PDA. The PDA and right posterolateral were filling via septal collaterals from the LAD. The proximal RCA CTO had a blunt stump, long occlusion length with occluded prior stents and diffusely diseased distal vessel that was filling via septal collaterals from the LAD.
We decided to use a primary retrograde through the occluded SVG-PDA. We successfully crossed the SVG using a Gladius Mongo wire and used a Sasuke dual lumen microcatheter to advance a Sion black retrogradely. We advanced a Corsair XS to the PDA and did tip injection, but retrograde crossing attempts with a Gaia Next 3 failed. We tried antegrade wiring but could only advance a wire to the mid RCA. Repeat retrograde attempts were successful in puncturing the distal cap with a Gaia Next 3, followed by knuckling of a Mongo wire to the mid RCA. We could not advance a guidewire further until after using the Carlino technique. We then did successful reverse CART with externalization of an R350 wire. Using the Sasuke we wire the right posterolateral followed by stenting of the distal to proximal RCA. Antegrade contrast injection caused a coronary and aortocoronary dissection, that was treated by stopping selective contrast injections and deploying a stent all the way to the aorta. A nice final result was achieved with resolution of the patient’s angina.
Category
Cardiology
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