Author + information
- Chun Hung Su1
Patient initials or identifier number
Relevant clinical history and physical exam
64 years old male
HCVD, hyperlipidemia, heavy smoker for 20+ years
Angina on 2006, CAG: Insignificant CAD
Acute lat. wall MI, CAD with single vessel disease s/p PCI of P-LCX on 2008
Worsen chest tightness and dyspnea since 2016/5
Relevant test results prior to catheterization
T1-201 SPECT scan: High probability of coronary artery disease in LCX territory
Relevant catheterization findings
RCA: P-RCA eccentric plaque with >80% stenosis
LAD: Unusual anatomy with patent vessel
LCX: LCX-ostium total occlusion without stump
(1) Try antegrade approach by LAD collateral flow guide?
(1) No stump and hard lesion: LM trauma by stiff wire?
(2) Unusual LCX ostium, use IVUS guide?
(3) Long CTO lesion, possible Long false lumen?
We tried antegrade approach first but failed
(2) Retrograde approach by LAD epicardial collateral with Fine-cross micro-catheter support and block-tip technique but failed to cross micro-catheter- -> Failed
(3) Adjust to angulated view to LAO:60 degree and caudal:30 degree and re-tried antegrade technique with only intermediate wire and success cross the CTO lesion. POBA followed by DES stenting and optimal final result of TIMI 3 LCX flow was detected.
(4) Performed P-RCA lesion
Antegrade procedure for LCX-ostium CTO lesion without stump is possible.
Adequate adjustment of angulated view is the key of successful PCI of ostium CTO lesion with unusual anatomy.
Ostial and ISR CTO lesions are not always hard and can try intermediate wire first.
Broken-tip wire technique is a good method to cross very tortus collateral channel, but the problem is difficult to cross micro-catheter.