Author + information
- Hsiang-Yao Chen1
Patient initials or identifier number
Relevant clinical history and physical exam
A 52 years-old male, smoker without any systemic disease or family history complained about progressive shortness of breath and chest tightness intermittently in recent 3 months. Symptoms could be relieved when taking a rest. There was no specific finding in physical examination.
Relevant test results prior to catheterization
EKG showed normal sinus rhythm. Treadmill test failed due to intolerable fatigue. Thallium scan showed ischemic area over anterior, apical and inferior wall.
|8 mg/dL||0.73 mg/dL||138 mmol/L||3.9 mmol/L||12 U/L||21 U/L||201 mg/dL||24 mg/dL||111 mg/dL||433 mg/dL||4.3 mg/dL||8300 /CUMM||15.7 g/dL||277000 /CUMM||0.99|
Relevant catheterization findings
CAG done via right radial artery. It showed CAD with DVD:LM: Patent LAD-M: 90% stenosisLCX: Patent RCA-M: total occlusion, J-CTO score 2LVG showed normal systolic function, LVEF: 66%
We chose the RCA CTO lesion as the main target. A total of two 7Fr femoral sheaths were punctured, one each on his right and left femoral arteries. For RCA lesion, a FL4/7 GC was engaged to LCMA and an AL 1/7 GC was engaged to RCA. Initially, we performed antegrade approach and used a Fielder FC GW and then a ProVia 12 GW under the support of the Sprinter 1.25 mm OTW to puncture the CTO lesion. But they both failed to cross this lesion. We then changed our strategy to retrograde approach. A Sion GW under the assistance of a Fine cross MC applied as my initial retrograde GW, and we chose a septal branch as the collateral. We had successfully advanced the GW to RCA-D and performed reverse CART. However, due to contrast extravasation noted at the very septal branch we performed retrograde approach. Antegrade approach forced to reconsider again. Combining IVUS and Crusade MC assisted parallel wire technique, we can identify the right re-entry point of the true lumen. This time, we succeeded in crossing the CTO lesion with a Progress 200T under the Crusade MC. We used the IVUS again to confirm the wire had entered the true lumen.
Finally, we performed sequential POBA, and then stenting with DES. The final result showed good TIMI III flow.
Intravascular ultrasound plays an essential role in the treatment of chronic total occlusion after the failure of both antegrade and retrograde approach. Parallel wiring technique assisted by intravascular ultrasound/Crusade MC is helpful in antegrade approach.