Case 283: Manual of CTO PCI - Jailed LAD CTO

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A patient was referred for PCI of an LAD CTO after a prior failed attempt. The LAD was occluded at the takeoff of a large diagonal branch with a stent placed from the LAD into the diagonal. Attempts to clarify the proximal cap ambiguity failed. Retrograde crossing was achieved from the PDA into the LAD through a septal branch but a Caravel microcatheter could not advance to the LAD. After inserting a 6 French Guideliner Coast, a Corsair microcatheter was successfully delivered to the LAD. Retrograde puncture into the LAD was extremely challenging. After multiple attempt and after inflating a balloon into the LAD/diagonal a Gaia Next 3 successfully crossed into the proximal LAD. IVUS confirmed that re-entry was distal to the left main bifurcation. The retrograde wire was advanced into the left main guide and a FineCross M3 was advanced into the guide, allowing externalization of an R350 wire. Using a Sasuke a wire was advanced antegradely into the LAD but it was in the extraplaque space. Using a Stingray balloon and the double blind stick and swap technique the LAD was successfully wired and stented.
Category
Cardiology
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