Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
Mr. LWY, a 54 year-old heavy-smoker, has diabetes and hypertension for more than 6 years. He also has dyslipidemia, gouty arthritis, stage 4 CKD and 2-V CAD which was treated by PCI with DES stenting to LCX one year before admission. RCA CTO found at that time but had a failed attempt to re-open(failed to cross LAD septal branch collaterals and antegrade approach by a stiff wire resulted in coronary perforation).He still had dyspnea and LVEF was 43%. Revascularization of RCA CTO was planned.
Relevant test results prior to catheterization
1. Regional wall motion abnormality with dilated LV and borderline LV systolic function, suggestive of RCA disease
2. LV grade I diastolic dysfunction
Relevant catheterization findings
Prior coronary angiography: Failed attempt to use septal collateral's last time. There’s another epicardial collateral's from LCX, but much longer and torturous.
Target lesion: Seg. 2-3 mid to distal RCA CTO. Approach:bi-radial artery. Catheter: 7Fr EBU 3.75 with 10 cm cut-short, engaged to LM from right radial artery; 6Fr SAL2 with side hole, engaged to RCA from left radial artery. We started from retrograde approach: a Sion wire in Corsair micro catheter was used to cross the long torturous epicardial collateral from LCX and reached RCA-PL branch. After Corsair catheter reached crux, retrograde wiring was further done by Fielder FC and UB3 wire but cannot cross the calcified spot and all went into sub intimal space. Anterograde wiring was then tried by Sion and Fielder XT wires in Pro great micro catheter but still failed. Retrograde wiring by Conquest Pro again was also failed. We tried R-CART at d-RCA by 2.5 mm balloon but cannot enter true lumen. Retrograde wiring was tried again by a new Fielder FC wire and then cross the calcified spot but may went into sub intima(however, the bi-directional wires seemed quite close to each other now). R-CART was performed again by 2.0 mm balloon at m-RCA and then retrograde wire entered the true lumen. Using a 6Fr guidelines into m-RCA to reach retrograde Corsair catheter, Rendezvous technique by retrograde wire succeed. Predilation was done by 1.5 mm mini-Trek, 2.0 mm, and 2.5 mm balloon catheter sequentially. IVUS was performed to ensure vessel size and plaque burden. After two long DES deployment and further post-dilation, good result of angiography and TIMI-3 flow were achieved.
In this case, long and torturous epicardial collateral's impaired torque ability of wires and made retrograde approach more difficult. Carefully advance of proper micro catheter helps to control wire and saves contrast. Reverse CART technique is useful to achieve true lumen while bi-directional wire goes close to each other in sub intimal space.