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Relevant clinical history and physical exam
A 61 year-old male suffered from chest discomfort on exertion. He had a history of per cutaneous coronary intervention (PCI) to left anterior descending (LAD) artery and left circumflex (LCX). Additionally, he received PCI to right coronary artery (RCA) chronic total occlusion (CTO) 1 year ago, but unfortunately failed.
Relevant test results prior to catheterization
His electro cardiogram did not show abnormal Q wave at inferior leads. His left ventricle systolic function was normal and no segmental wall motion abnormalities. We found ST-T depression during exercise stress testing.
Relevant catheterization findings
We performed diagnosis catheter firstly, we found CTO of RCA. This RCA was shepherd’s crook type and CTO length was so long and very tortuous. We found collateral from LAD and LCX and proximal RCA.
The CTO length was so long and very tortuous. On addition, this RCA was shepherd's crook type and previously tried to treat, so, we thought it was so difficult to treat with only antegrade approach. Therefore, we decided to start retrograde approach firstly.
A 7Fr SAL-1.0 SH (Medtronic) engaged in the right and a 7 Fr EBU-3.75 SH(Medtronic) in the left coronary artery through bi-femoral approach.
We checked septal channel by tip injection. We found hairpin curve, so we bent SION (ASAHI) bigger and succeeded in crossing with Caravel 150 cm (ASAHI). The wire advanced CTO exit part and changed the wire from SION to ULTIMATE bros 3.0 (ASAHI).
Then, the antegrade approach was tried using Miracle Neo 3.0 (ASAHI), and Corsair 135 cm (ASAHI) because we could not detect correct direction. We used a Guide liner (JAPAN Lifeline) because we needed strong back up to advance guide wire from antegradely. We succeeded close to each guide wire.
Following a 2.5 mm semi-compliant balloon inflation, Guide liner was proceeded. We performed the reverse-CART technique with this balloon. Retrograde wire was inserted into Guideliner, and we performed externalization with RG3 (ASAHI). We dilated with the balloon and implanted four everolimus-eluting stents. Final angiogram showed successful revascularization at RCA long CTO lesion. We used only 80 cc amount of contrast medium (Omnipaque).
It was so difficult to treat with only antegrade approach because CTO length was so long and so tortuous and its RCA was shepherd’s crook type. Like this case bi-directional approach is necessary. To keep the guide wire in the vessel is so important, so we used Ultimate bross 3.0 and Miracle Neo 3.0. And using Guide liner is so useful for this case to get enough backup.