Case 277: Manual of CTO PCI - Too far?

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A patient with prior CABG and occluded SVG-PDA was referred for a repeat attempt to recanalize a right coronary artery CTO. The RCA CTO had an ambiguous proximal cap, 30 mm length, bifurcation at the distal cap and distal filling via both septal and epicardial collaterals. A primary retrograde approach was successful in crossing to the PDA. Reverse CART was challenging. IVUS showed the antegrade wire to be in the true lumen and the retrograde wire in the false lumen. After using a larger antegrade balloon the retrograde wire crossed into the antegrade guide catheter followed by externalization of an R350 wire. Attempts to wire the posterolateral over a Sasuke microcatheter failed. An attempt for crossing to the posterolateral through an epicardial collateral also failed. The patient was stable without pericardial effusion or tamponade. The collateral was successfully coiled but the perforated segment kept on filling through another collateral. The 2nd collateral was coiled too, achieving hemostasis. The patient had an uneventful recovery.
Category
Cardiology
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