Author + information
- Dharmaraj Karthikesan1,
- Kantha Rao Narasamuloo1,
- Kai Soon Liew1,
- Ahmad Faiz Mohd Ezanee1,
- Gerard Jason Mathews1,
- Yi Zhi Cheng1,
- Ahmad Shukri Saad1,
- Wan Faizal Bin Wan Rahimi Shah1,
- Huan Yean Kang1,
- Saravanan Krishinan1 and
- Chee Tat Liew2
Patient initials or identifier number
Relevant clinical history and physical exam
A 54-year-old man, non-smoker, with underlying hypertension presented with symptoms of exertional angina for 6 months duration. Exercise stress test (EST) was positive and echocardiogram showed good left ventricular function.
Relevant test results prior to catheterization:
Relevant catheterization findings
Coronary angiography revealed chronic total occlusion (CTO) of mid left anterior descending artery (LAD) and proximal right coronary artery (RCA). Left circumflex artery (LCX) had minor disease. His percutaneous coronary intervention (PCI) involved a two-step approach. Ad hoc PCI was first attempted to the CTO LAD which was successfully implanted with a single drug-eluting stent (DES). He was planned for a staged PCI to CTO RCA later.
First attempt at CTO RCA started with 7Fr EBU 3.5 guide for LAD but difficulty was encountered when engaging the RCA due to an ostial lesion. Started with AL 1.0, then XB RCA and finally JR 4.0. The initial strategy was an antegrade approach but failed despite multiple attempts including the use of parallel wire with Fielder XTA and Gaia first. Changed to retrograde approach using LAD mid-septal collateral but unable to wire into the right posterior descending artery (RPDA) with Sion Blue due to the angulation. Changed to Fielder XTA but caused perforation into right ventricle (RV) cavity. Echocardiogram showed no effusion. Retrograde attempt was abandoned. Reattempted antegrade with Gaia Second and Conquest Pro wire but failed due to poor guide support and wire tracking into false lumen causing dissection. Procedure was abandoned and was planned for a reattempt via retrograde approach later.
Reattempted 1 month later starting with retrograde approach using 7Fr EBU 3.5 and 6Fr JR 3.5. We noted absence of interventional collaterals probably due to occlusion from previous perforation. Proceeded with antegrade approach using anchor balloon technique to conus branch. With good guide support, CTO was crossed using Fielder XTA wire. The vessel was prepared accordingly and diffuse distal RCA disease was treated with a drug-eluting balloon. Distal to ostial RCA lesion was stented with an overlapping DES 2.5 x 40 mm and 3.0 x 30 mm. Optimal postdilatation was done using a non-compliant balloon.
Final angiography results were excellent with the absence of perforation or dissection. He was discharged well and remains asymptomatic of angina. This case has several learning points. Firstly, it demonstrates that a perceived initial difficult approach may turn out to be the safest approach to successful CTO intervention. Secondly, it shows good guide support is essential in CTO intervention with challenging ostial lesion and demonstrates various techniques to improve guide support. Finally, use of soft wire is essential to negotiate collateral channels as hydrophilic wires tend to cause perforation of collateral channels.