Author + information
- Cheng-Hung Chiang1
Patient initials or identifier number
Mr. Huang, 46 years old male
Relevant clinical history and physical exam
History of hypertension and type 2 diabetes, dyslipidemia under medical control.
Dyspnea on exertion at functional class II activity for half year.
Physical examination showed mild S3 without obvious murmur.
Relevant test results prior to catheterization
The cardiac SPECT showed partial reversible defect in apical-to-middle inferior wall (70% decrease to 50% decrease) and persistent defect in basal inferior wall (60% decrease) and reversible defect in lateral wall (30% decrease).
The echocardiogram showed generalized hypokinesia of left ventricle especially basal infero posterior wall mild left ventricular (LV) systolic dysfunction estimated left ventricular ejection fraction (LVEF): 52% mildly dilated left atrium with trivial tricuspid regurgitation, mild mitral regurgitation
Relevant catheterization findings
Right coronary artery: Total occlusion at proximal site with self antegrade bridging collateral
Left anterior descending artery: Critical stenosis over proximal part
Left circumflex artery: Critical stenosis over distal part
PCI over Lcx done first and then tried antegrade approach of right coronary artery chronic total occlusion. It failed and the plaque was not easy to pass. Then we tried retrograde approach. We had two channel to go, the first is septal branch the other is via AV groove by circumflex. The image of distal septal to right coronary is not clear at cranial view but much more clear at right anterior oblique view. We pass retrograde sion wire up to right coronary middle portion but failed to enter chronic total occlusion. We then tried Gaia 3 wire, but still failed.
Later we use 2.5 balloon for reverse controlled antegrade and retrograde subintimal tracking and then pass retrograde wire into antegrade guiding catheter. We the do externalization and check IVUS via antegrade and then finish the procedure.
For round stump chronic total occlusion with left antegrade bridging collateral, the antegrade approach was not always easy and in our case, we failed in antegrade approach. In this case, the important key to success is the choice of retrogade channel and as it was not clear. Choosing another angulation of angiogram is important. The other is: as we meet difficulties in advancing retrograde microcatheter, we can do anchor balloon technique in stead of deep seating retrograde guide to avoid complication.