Author + information
- Masaki Tanabe1
Patient initials or identifier number
Relevant clinical history and physical exam
A 71 years-old male patient suffered from chest oppression on effort and he admitted to our catheterization to undertake re-attempted PCI. He had a chronic total occlusion (CTO) at the mid to distal right coronary with lotus root-like appearance and severe tortuosity with two big curves. He had been undertaken coronary intervention to this RCA-CTO in 2008 in our cardiac catheterization laboratory, but without success due to failure of passing guide wires.
Relevant test results prior to catheterization
According to his medical report, his onset of inferior myocardial infarction was in 1994. Coronary angiography completely occluded at the mid RCA in those days. In 1995, The RCA had a specific lesion with lotus root-like appearance at the mid portion in his restudy angiography.
Relevant catheterization findings
RCA had a CTO at mid to distal site with lotus root like appearance.
Moreover, the morphology of RCA was significantly tortuous having two acute curves.
The distal branch of the PL branch of RCA had occluded completely, which supplied by contra lateral collateral's. However,there was no interventional collateral.
The LCA had no re stenosis at the LCX which had been underwent PCI at the ostial LCX, and the LAD which had been underwent PCI's at the proximal to mid portion.
The PCI to the mid RCA-CTO started by right trans femoral approach after guide catheters insertion using the 8Fr JR4 with side holes to the RCA ostium. Regarding retrograde approach, it was not considered because of no interventional collateral. Firstly, antegrade wiring started using the Gaia 1st with the Corsair micro catheter support. It managed to penetrate into the CTO entry but was not able to advance just after the CTO entry. Therefore, the Gaia 1st exchanged to the Gaia 2nd. The Gaia 2nd managed to cross over the 1st acute curve into the CTO segment, however, it was not able to advance anymore.
Consequently, wire escalation of Miracle brothers (Miracle 6g and 12g) performed, but, did not work. These wires was not able to follow the direction of the 2nd curve but advanced in a linear manner. Therefore, re-attempting antegrade wiring using the Gaia 2nd was performed for negotiation the 2nd curve of into the CTO segment. Eventually, wire manipulation with the Gaia 2nd was successful in negotiating to the 2nd curve of into the CTO segment. And then, it advanced into the distal CTO segment after successful passing through the 2nd curve of the CTO segment, and it was successful in passing through all the CTO segment antegradely. Two new generation SESs were implanted over the CTO segment as a final procedure.
The final angiography had a satisfactory image because of successful interventional revascularization of the RCA.
Wire selection and wire manipulation of the Gaia 2nd worked strategically, in case of the performance of antegrade the RCA-CTO PCI with lotus root like appearance and severe tortuosity having two acute curves for successful in interventional revascularization.