Case 278: Manual of CTO PCI - Mega Carlino

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A patient was referred for PCI of a mid LAD CTO after a prior failed attempt. The LAD CTO had a blunt proximal cap at the takeoff of a large diagonal branch, length of approximately 20 mm with significant calcification based on coronary CT angiography, good quality distal vessel and distal filling via ipsilateral epicardial collaterals. Antegrade wiring with a Gaia Next 2 resulted in extraplaque crossing. Parallel wiring failed. We attempted re-entry with a Stingray balloon and a guide extension to block antegrade flow without success. An inadvertent injection (Mega Carlino) caused a large extraplaque hematoma extending to the distal LAD. Retrograde crossing via epicardial collaterals failed. We performed the STRAW technique (subintimal transcatheter withdrawal) to aspirate the extraplaque hematoma: a balloon was inflated proximally followed by aspiration through the Stingray balloon using a Penumbra pump. This facilitated successful re-entry into the distal true lumen using the Stingray balloon with a nice result after stenting. There remained mild extraplaque distal hematoma that was treated with balloon angioplasty.
Category
Cardiology
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