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Patient initials or identifier number
Relevant clinical history and physical exam
The patient was a 77-years-old male. He had felt dyspnea on effort from few weeks ago. He had received hemodialysis for twelve years. He was treated as hypertension and diabetes mellitus and received some medication. But he has not smoked ever and had no family history of coronary artery disease and stroke. He performed percutaneous coronary intervention (PCI) for right coronary artery (RCA) 2 years ago and for left anterior descending (LAD) twice 2 years and 4 years ago.
Relevant test results prior to catheterization
The electrocardiogram (ECG) revealed complete right bundle branch block and premature ventricular contraction. The echocardiography revealed inferior hypokinesis, and ejection fraction was 60%.
Relevant catheterization findings
Coronary angiography (CAG) revealed RCA was chronic total occlusion (CTO) at proximal segment. Distal RCA was filled by the collaterall circulation from LAD septal branch to RCA distal branch. And we found small island at mid RCA.
We used a 7 Fr JR 4.0 SH (Medtronic) guiding catheter from right femoral artery. Firstly we used Ultimate bros 3 (ASAHI) with Corsair (ASAHI) for antegrade approach. We could advance the wire and corsair to island at mid RCA, and performed tip injection. We found totally long occluded from mid to distal. So we decided to start retrograde approach. We used a 6 Fr EBU 3.75 SH (Medtronic) guiding catheter from left femoral artery. We used XT-R (ASAHI) with Corsair Pro (ASAHI) for septal channel tracking. After crossing channel, we changed the wire to Ultimate bros 3, but could not advance the wire to mid RCA because of severe calcification. Therefore we stared antegrade wiring by using Conquest Pro (ASAHI) with Corsair. On the way, we changed antegrade system to 7 Fr SAL 1.0 SH (Medtronic) with Guidliner (Japan Lifeline) to get enough backup. Fortunately, we could advance Conquest Pro and close to retrograde wire, so we performed rendezvous technique at mid RCA. After randezvous technique, we could advance the wire to distal RCA. Then we could dilate small balloon and performed externalization with RG3 (ASAHI). We found severe entire circumference calcification from intravascular ultrasound findings and we thought Rotational Atherectomy necessary. We performed debulking by 1.75 mm barr. After debulking, we could dilated by Sapphire 2 NC 2.5 x 15 mm (Orbusneich) and Hiryu Plus 3.0 x 20 mm (TERUMO). Finally, CAG revealed good antegrade flow and no complication.
Like this severe calcified hemodialysis CTO case, it was enormously difficult to cross the wire even though performing both antegrade and retrograde approach. We succeeded in crossing the wire by rendezvous technique. Patient with severe calcification especially in hemodialysis needs various CTO techniques.