Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
Male 44 year old. Chest tightness off and on for 2 years
Risk Factors: hyperlipidemia, smoking and positive family history (father had history of CAD with MI s/p CABG) cTnI: Normal ECG Show: Normal sinus rhythm
Relevant test results prior to catheterization
UCG Show: Global EF: 63%, normal in systolic function, no significant valvular disease
CTA show: proximal LAD chronic total occlusion(CTO)
Relevant catheterization findings
1) LMCA: Patent
P/3: Stumpless CTO, just distal to Db2 branch side
Db1: Major branch, giving collateral flow to d-LAD via epicardial channel and Db4
3) LCX: Luminal irregularity.
D/3:tandem eccentric lesion, 70-80% stenosis
4) RCA: Luminal irregularity.
M/3: tandem eccentric lesions, 50%-60% stenosis
D/3:tubular concentric lesions, 80% stenosis
Giving collateral flow to m-LAD from Conal branch and epicardial channel
1. Perform anterograde wiring using the IVUS and CTO calcified cap as a marker.
2. Gaia II wire tip was directed to CTO proximal CAP under IVUS guide but always slipped into Db2 because of stumpless CTO and poor support.
3. Conquest pro wire supported by Crusade double lumen MC penetrated proximal CTO calcified cap but entered into false lumen.
4. Perform ipsilateral retrograde approach through epicardial collaterals from Db1 to Db4 and mid-LAD by using SION loaded in Corsair 150 cm MC.
5. Tip injection induced m-LAD dissection. Retrograde Gaia II wire always entered into septal branch or dissection channel.
6. The Miracle 6 wire retrogradely penetrated distal CTO CAP by using calcified lesion of CTO cap as maker and was advanced to mid-LAD and finally successfully crossed m-LAD CTO. The wire was advanced through proximal LAD, left main and to aorta.
7. Ipsilateral double guide catheters technique was performed by engaging another EBU 3.5(6Fr) guiding catheter to LMCA ostium via right radial artery access.
8. RG-3 330cm wire replaced the Miracle 6 wire through retrograde microcatheter and was successfully externalized through EBU3.5 (6Fr) guiding catheter.
9. Implant Stent (Xience Xpedition 2.75 x 48 mm) at the middle LAD and another Xience Xpedition 3.0 x 12 mm) at the proximal LAD.
Anterograde approach for stump less CTO could be facilitated by coronary CTA or assisted by IVUS but might still fail due to anatomical limitation and severe calcified. We describe a patient with stump less CTO of LAD in whom anterograde approach failure but finally successfully recanalization by using IVUS and coronary CTA image guided. Finally, two stents were implanted in the proximal and middle LAD respectively.