Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 58 year-old man with history of Hypertension, LVEF 67 Body Height 167 cm, Body weight 111 kg Creatinine 0.93 mg/dl Unstable angina pectorisHistory of -PCI to proximal to mid RCA (2015-2-27) in acute inferior STEMI setting with two BMS (5 x20 mm) complicated by percusurge wire fracture (trapped inside RCA ). -PCI to mid LCx (2015/3/2) with one DES(3.0x38 mm)
Relevant catheterization findings
5F sheath via right ulnar artery then switch to sheathless .
6F sheath via LRA
Diagnostic catheter : 5F IL4 (Ikari Left 4)
Guiding catheter :
7F EBU4 for LMC engagement (trans ulnar sheathless)
6F IL4 for RCA engagement
Coronary angiogram findings :
LM : No stenosis
LAD : CTO at its proximal segment with grade III collaterals from OM branch
LCx : Mid segment had patent prior stent
RCA : Patent prior stented proximal to mid segments with prior fractured percusurge wire inside
We directly aimed for retrograde approach through OM collaterals to LAD because the patient had a failed previous antegrade trial, we used Fine cross 150cm microcatheter with 0.014” Runthrough, fielder FC and Sion guidewires, but failed resulting in Type F OM dissection. We shifted to antegrade approach with Crusade microcatheter with Runthrough to septal branch and Gaia 2nd to LAd which passed subintimally, we reloaded the crusade on the Gaia 2nd and advanced Conquest Pro 12 which successfully crossed the CTO segment to distal LAD. Sequential dilatation with 1.2, 2.5, 3.0 and 3.5 balloons was performed followed by IVUS interrogation and BVS deployment (2.5x28mm)to distal LAD, then we experienced technical difficulty to pass the next BVS to mid LAD so we used 5 in 7 (Child and mother technique) to deploy a BVS (Absorb 3.0x28mm) at mid LAD then finally (Absorb 3.5x28mm) at proximal to mid LAD covering the proximal LAD aneurysm.
TUA approach is safe and feasible alternative wrist access, providing high success rate and low incidence of vascular complications.(Catheter Cardiovasc. Interv. 2014 Jan 1;83(1):E51-60).
In patients with Radial artery occlusion, ipsilateral trans-ulnar catheterization may not be an absolute contraindication ,extensive collaterals from the anterior interosseous artery may be the reason for protection against hand ischemia . (Catheter Cardiovasc. Interv. 2013 Dec 1;82(7):E849-55).Crusade microcathter facilitated parallel wire technique to recanalize CTO. A 3.5x23 mm BVS would have been more suitable than 3.5x28 mm .