Author + information
- Chiung-Ray Lu1
Patient initials or identifier number
Relevant clinical history and physical exam
This 49-year-old man with hyperlipidemia diagnosed with 2V-CAD, CTO of LAD in 2015 June 16. He received Mini-CABG (LIMA-LAD, robot-assisted LIMA take down) on 2015 July 02. He still had exercise intolerance after operation. The physical exam was unremarkable.
Relevant test results prior to catheterization
ECG normal sinus rhythm.
Relevant catheterization findings
2016 Aug 9 diagnostic coronary angiogram
LAD -Proximal CTO (no stump, just behind 1st DB)
LCX -Proximal 40% stenosis
RCA -Middle 70% atheroma, PLA 70% stenosis
Collateral-from RCA to LAD
LIMA-2nd DB: Patent without filling the LAD
PCI to LAD performed via bilateral radial artery by antegrade and retrograde approach. The LCA engaged with 6 Fr EBU 3.5GC. The 1st DB wired with Sion GW then IVUS performed for puncture the CTO of LAD. Crusade MC used and the CTO lesion tried to wire by Gaia 1,Wizard 3 and Progress 80 GW but all failed. Then it switched to retrograde approach. The RCA engaged with JR 4.0GC. A 150 cm Corsair was used. The retrograde channel was wired with Sion GW but failed. Then antegrade approach was tried again with Progress 120 GW. The lesion was successfully penetrated and wired into true lumen under Progreat MC support. The MC changed to Corsair by extension wire. After sequential dilation with Mini-Trek 1.5/12 mm, sprinter 2.0/20 mm and 2.5/20 mm BC. IVUS performed again. The lesion stented with Synergy 2.5/24 mm and 3.0/28 mm stent. Post-dilation with NC Euphora 2.5/12 mm BC 12-20 bars and NC Quantum 3.0/15 mm 12-18 bars was done.
Final result: TIMI-3 flow, RS <10%. The RCA was treated with synergy 3.0/20 mm and 4.0/16 mm stent two days later.
The coronary chronic total occlusion is a challenge to an cardiac interventionist. The IVUS guidance puncture may be useful in CTO with big side branch and without a stump. Carefully antegrade wiring with adequate entry point can prevent long stenting due to dissection.