Case 245: Manual of CTO PCI - Failed LCx CTO PCI

A patient was referred for PCI of an ostial circumflex CTO. The CTO was located distal to a ramus branch with ambiguous proximal cap, length of approximately 20 mm, good quality distal vessel and filling via an epicardial collateral from the ramus. Coronary CT angiography showed severe calcification of the distal left main and the LCx origin. IVUS failed to clarify the location of the proximal cap due to calcification, but an estimation was made based on the CT angiography findings. Antegrade wiring attempts with various penetrating guidewires (including Gaia Next 3, Confianza Pro 12, and Hornet 14) failed despite using a Sasuke dual lumen microcatheter, a Venture and a SuperCross. We decided to go retrograde and successfully crossed into the distal obtuse marginal branch with a Suoh 03 guidewire. However, retrograde wire puncture failed: the retrograde guidewires entered into the extraplaque space around the left main. Due to risk of compromising the LAD and ramus with extraplaque crossing in the left main we decided to stop the procedure. The patient did not have any complications.

[@zadigbalaban8359]

It is sometimes better to know when to stop, and when Brilakis stopped then everybody should stop. Thank you Emanuel Brilakis for nice explanation as always

[@shangz0216]

Thanks for the educative case presentation.

[@NikhilJha89]

Lcx CTO are the most challenging.
Sometimes not to do anything is better.

[@tom11298]

Two enemies here significant calcium at the ostial occlusion and having the LM.
Perfect is enemy of good and the elderly pat was given a very good chance for treatment. Optimizing medical treatment is a good idea including medications that can increase the flow to collaterals like Ivabradine.

[@maisamtaherian986]

Thank you very much ❤ Is it worth using Astato 20 to puncture the ostioproximal antegradely?

[@wbcjunior]

Why didn't you take BASE to try to enter the subintima?

[@ruotianli8785]

Antegrade wiring even when subintimal. Reverse CART in proximal circ and if it fails, Stingray balloon based reentry with the retrograde wire as a marker.

[@NikhilJha89]

Not worth taking risk with left main

[@usetherightbrain.]

ostial occlusion are a challenge, but what was your plans for stent placement if you were able to cross?

[@manosbrilakis]

DK crush (to maintain wire position in the LAD at all times)