Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
This is a 55-year-old gentleman who was referred for further management. Following recurrence of angina for the past 3 weeks. He was currently in CCS III. Premorbid medical history includes dyslipidemia and acute myocardial infarction in 2011, where by a coronary artery bypass grafting (CABG) with a LIMA to diagonal artery performed. Physical examination was unremarkable.
Relevant test results prior to catheterization
Echocardiography revealed ejection fraction of 48%, hypokinesia at mid to apical anterior and anteroseptal walls with normal valves.
Relevant catheterization findings
Left main and right coronary artery were normal. The left anterior descending artery totally occluded from ostial to proximal segment and there was a severe stenosis at the mid segment. The left circumflex artery had moderate stenosis proximally. The left internal mammary artery (LIMA) graft to diagonal artery was patent.
Access: Right radial and right femoral (contralateral injection)
Guiding catheters: EBU3.5 7French and IMA 6French
Antegrade approach was first attempted by wiring the LCx with Run through Floppy and the LAD with Fielder XTA with a Fine cross micro catheter support. Wires were then upgraded gradually to Conquest Pro, Conquest Pro 12 and Conquest Pro 8-20 but due to high calcification, the wires kept getting deflected and going into false lumen. The antegrade approach was then switched to retrograde approach.
Retrograde approach was attempted by wiring the LIMA-Diagonal and backward into mid LAD with Sion Blue wire, which successfully crossed the severe stenosis at mid LAD into the distal LAD. Attempts to advance Tazuna 2.5/15 mm balloon into mid LAD via the LIMA-Diagonal graft was unsuccessful due to its tortuosity and thus a Guideliner with a Whisper wire was used. Tazuna 2.5/15 mm balloon was finally able to pass down and the mid LAD lesion was predilated. Mid LAD-Diagonal bifurcation was then predilated (modified CART). Using the retrograde wire as a guide, the antegrade wire (Conquest Pro 8-20) was finally able to cross the distal cap of the CTO. The CTO was predilated with Tazuna 1.5/15 mm then 2.5/15 mm. Ostial to proximal LAD was stented with Orsiro 3.0/40 mm and post dilated with NC Euphora 3.5/20 mm.
This case resulted in a TIMI III flow in the native LAD artery. The diagonal branch flow did not compromised despite being jailed at its ostium after the LAD stent deployed, as it was separately supplied by the patent LIMA graft. To be successful in tackling a CTO lesion, one has to be proficient with the antegrade and retrograde approaches and quickly switch from one to another. Several techniques that were employed in this case included anchor wire, kissing wire, mother-child-grandchild and modified CART. Guideliner support was helpful to negotiate the tortuousity in the LIMA but one has to be gentle and careful to avoid dissecting it.