Author + information
- Rei Fukuhara1
Patient initials or identifier number
Relevant clinical history and physical exam
A 54-year old man admitted our institute with electrocardiographic abnormality pointed out at periodic health examination. He had never felt chest pain. His coronary risk factors were diabetes, dyslipidemia, hypertension and current smoking. Physical examination revealed no significant findings. Although we recommended CABG, the patient rejected and we planned complete revascularization by PCI. Subsequently to PCI for LCA lesions, we carried out PCI to the RCA CTO lesion.
Relevant test results prior to catheterization
Chest X-ray was unremarkable. ECG showed abnormal Q wave in inferior leads and decreased motion at inferior wall with 50% of EF was observe by echocardiogram.
Relevant catheterization findings
1. Right coronary angiogram showed chronic total occlusion at Seg 2.
2. Left coronary angiogram showed moderate stenosis at mid LAD and subtotal lesion at mid LCx.
We firstly performed bilateral coronary angiography but could not visualize the CTO exit clearly. Therefore, we started the procedure by the retrograde approach. Although septal channel had some bending at the distal part, we successfully negotiate XT-R to distal LAD. However, not only Corsair but also Mizuki could not cross this bending part. Therefore, we had to move to integrate wiring with a landmark of CTO exit by a retrograde guide wire. Although we stepped up the antegrade guide wire to Gaia 2nd, we could not advance the guide wire to a distal part of CTO because there existed some bending in CTO lesion and could not presume the appropriate vessel course. Then we considered retrograde approach was necessary to accomplish this procedure and changed the retrograde tube catheter to a new Corsair. Fortunately, a new Corsair could cross the bending part of the channel and we started retrograde wiring by using Ultimate bros 3. We successfully advanced the retrograde guide wire into the proximal part of CTO and verified it was located in the plaque by antegradely inserted IVUS. From the concept of contemporary rCART, the small sized balloon catheter was enough to negotiate retrograde guide wire to proximal true lumen. However, this concept was completed in case of using a controllable guide wire, like Gaia series, retrogradely. In this case, we could not control the retrograde guide wire precisely due to some reasons. Therefore, we chose classical rCART by using 3.5 mm sized balloon and succeeded to open this CTO.
Contemporary rCART is an effective concept to preserve retrograde guide wire controllability by avoiding making unnecessary space in the vessel. But there exist some situations which cannot utilize this concept like this case. We should estimate the situation precisely and choose the appropriate method.