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Relevant clinical history and physical exam
A 67-year old male patient visited our hospital because of exertional angina. He had risk factors of hypertension, old cerebrovascular accident, peripheral arterial occlusive disease and ex-smoker (30 pack-year). He was already diagnosed with stable angina and proximal RCA chronic total occlusion (CTO) 7 years ago. He maintained an optimal medical treatment, but his symptom not improved. Therefore, we decided to perform percutaneous coronary intervention for this CTO segment.
Relevant test results prior to catheterization
Echocardiography showed mild hypokinesia on inferoseptal and inferior wall with preserved left ventricular systolic function (EF 52%).
Relevant catheterization findings
By using femoral approach with 7-Fr sheath, angiography revealed chronic total occlusion at proximal RCA (pRCA)with bridging collateral flow. Proximal stump of CTO segment was not clearly visible. Furthermore, collateral from left coronary artery was poorly developed.
Because collateral flow from left coronary was poorly developed, we had to perform CTO intervention in antegrade approach. To overcome, stump less CTO, we decided IVUS-guided wiring. At first, we introduced the floppy guide wire(RunthroughTM, Terumo, Japan) to proximal side branch for IVUS evaluation. IVUS imaging clearly revealed proximal part of occluding segments. Then, we tried to penetrate with Fielder XT-A under micro catheter (FinecrossTM, Terumo, Japan), and the guide-wire easily slip to the proximal cap of CTO segment. However, it could not pass through the distal CTO segment. We changed guide wire to a stiff guide-wire (GAIA second, ASAHI,Japan). The guide wire successfully passed into target lesion. Then, sequential balloon angioplasty was performed, and IVUS imaging showed that RCA vessel diameter about 3.0 mm. We implanted 2.75 x 28 mm drug-eluting stent (DES) (Synergy,Boston), 3.0 x 32 mm and 3.5 x 20 mm DES at from distal to proximal RCA. Final angiogram revealed showed TIMI 3 flow with preservation of all side branches. After procedure, his symptom was much more improved and discharged without any complications.
When dealing with stump less chronic total occlusion (CTO) and no viable retrograde option, the only way to perform recanalization is through anantegrade approach. IVUS is useful tool to identify correct entry point of stump less CTO.