Author + information
- Eric Silvio Chong1
Patient initials or identifier number
Relevant clinical history and physical exam
A 55 year old man with history of diabetes, hypertension, hyperlipidemia and smoking. He presented with anterior STEMI with cardiogenic shock who under went PCI to proximal LAD and LCx during the first presentation. He has a residual proximal RCA CTO. One week after the initial PCI, patient was clinically stable. He was keen to undergo PCI to RCA CTO. MIBI viability scan showed viable RCA territory.
Angiogram is shown:
Relevant test results prior to catheterization
Full Blood Counts was normal: Hb 14.5g/dl, platelet = 233 x 10(9)/L
Renal function was normal: Cr = 80 mmol/l, urea = 10 mmol/l
HBA1C = 8%, LDL = 5.1 mmol/L, HDL = 0.9 mmol/l, Triglyceride = 2.3 mmol/l
Echocardiogram showed LVEF = 50%, normal cardiac valves, mild hypokinesia in anterior wall and normal contractility in the inferior wall
CXR showed cleared lung fields
Relevant catheterization findings
Left main, normal
Proximal LAD stented with a 3.5 x 28 mm Xience Alpine stent during the first PCI
Proximal LCx stented with a 2.75 x 28 mm Xience Alpine stents during the first PCI
Proximal RCA has a CTO, heavy calcium was present.
There was long retrograde collateral supply to distal RCA from LAD via septal branches.
The septal collaterals were small and tortuous
Right radial Hockey Stick guider and femoral 6F EBU 3.5 Guider assess. Antegrade PCI to RCA CTO attempted first. A Run through wire via a 135 cm Corsair mircro catheter support used to reached the proximal CTO. A Gaia 3 wire was tried. However, the proximal CTO Cap was hard, A Conquest Pro 12 wire then used to penetrate the proximal CTO Cap. The Conquest Pro 12 wire and Gaia 3 wire used interchangeably for downstream tracking and drilling through the CTO. The Antegrade drilling was not easy. Despite the effort, the distal RCA true lumen could not be reached. The Corsair and Gaia 3 wire then parked at the mid RCA subintimal space. We proceeded to retrograde PCI using a Run through wire in a 150 cm Corsair micro catheter. The retrograde wiring was relatively easy, Run through wire traveled via first septal to RPL then distal RCA. Advancement of Corsair micro catheter was difficult.
We adapted a screw and wait technique and finally advanced the Corsair microcatheter to distal RCA. A Gaia 3 and then a Conquest Pro 12 wire was used to penetrate the distal CTO cap. Reverse CART technique was applied. Antegrade POBA with a 2 x 12 mm balloon to enlarge reentry subintimal space. A Conquest Pro 12 wire used to enter into proximal RCA. A Run through wire exchanged to enter into RCA guider and followed by RG3 wire externalisation. Antegrade predilation performed with 2.5 x 15 mm Trek balloon. 3 Xience Alpine stents (3.5 x 48, 3 x 28, 2.75 x 18 mm) were deployed and post-dilated.
This case demonstrates Reverse CART PCI to a Calcified RCA CTO. Both Proximal and distal CTO caps were calcified and hard for Gaia 3 wire to penetrate. Both Caps were penetrated only by using Conquest Pro 12 Wire. During the retrograde step, the retrograde advancement of Corsair catheter was very difficult but successful after very patient rotational screwing of the Corsair Catheter and adapting a wait and screw technique . Finally, the retrograde re entry to proximal RCA true lumen was difficult and attempted from different proximal RCA reentry points. Several good tips and tricks could be shared during this difficult retrograde PCI case.