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Patient initials or identifier number
Relevant clinical history and physical exam
A 55-year old man presented with intermittent chest tightness for 2 months. His coronary risk factors were hypertension, diabetes and current smoker (30 years, 20 cigarettes per day). He visited primary clinic and CT angiography showed severe stenosis in LAD and LCX and mild stenosis in RCA. The physical examination was normal.
Relevant test results prior to catheterization
ECG was normal. UCG showed normal ventricular wall motion and LVEF 70%. Blood routine,hepatic function, renal function, blood electrolyte and cardiac biomarker (cTNT, CK-MB and BNP) were normal. Total cholesterol was 4.82 mmol/L and LDL-c 3.24 mmol/L.
Relevant catheterization findings
A left coronary angiography showed severe stenosis at p-mLAD and total occlusion at mLAD, And dLAD well filled through the rich collateral channels from septal; severe stenosis at osD1, and significant stenosis at pLCX (Movie 1, Movie 2).
A right coronary angiography showed moderate stenosis at dRCA and severe stenosis at PL (Movie 3).
Firstly, left coronary ostium cannulated with a 6 Fr EBU 3.5 guiding catheter through right radial approach. We tried anterograde approach at mLAD CTO by using Conquest pro, Pilot 150 guide wires, and a Fine cross ®150 cm micro catheter but failed. We changed our plan to access retrograde approach via septal collateral channel (movie 4). We tried several wires (Sion, Pilot 150, Gaia First, Miracle 3) with Fine cross ® 0.014 inch 150 cm micro catheter, but all failed. After several attempts of retrograde approach, we came back to anterograde approach by using 0.014 inch Conquest pro wire and succeeded passing through the CTO lesion. Then we advanced the Sion wire retrogradely through the CTO lesion via micro-channel and push the Fine cross ® 0.014 inch 150 cm micro catheter through the CTO to pLAD (movie 5).Next, the retrograde wire was exchanged into a 0.014 inch 300 cm RG3 wire. And then we performed several balloon dilatations at proximal-distal LAD with Tazuna 12.5 x 10 mm balloon, Tazuna 2.0 x 20 mm balloon. After predilatation, we deployed 3 consecutive stents with overlapping at ostium-distal LAD (Xience Xpedition stent 2.75 x 38 mm, 3.5 x 12 mm and 4.0 x 15 mm), then we performed post-dilatation with Demax Gusta NC 3.0 x 15 mm and Demax Gusta NC 4.0 x 10 mm balloon. At last, we dilated distal LAD with a DCB (Sequent Please 2.5 x 30 mm, 6 atm, 50 seconds). The final angiogram showed successful revascularization at LAD CTO lesion (movie 6).
With suitable anatomy, successful revascularization of LAD CTO with septal collateral channel can be achieved. Despite tow right angles in septal to LAD collateral channel in our case, devices today still have chance to cross the angle. We alternated antegrade and retrograde intervention at the right time and finally crossed the CTO lesion. EBU guide catheter provided adequate support, which is especially important while antegrade and retrograde intervention are carried out through the same guide catheter.