Case 164: Manual of CTO PCI - When should you stop?!

A patient with prior coronary artery bypass graft surgery was referred for PCI of a right coronary artery CTO due to medically refractory angina. He had ostial RCA CTO with severe calcification. The occlusion was extending from the ostium to the right PDA/right posterolateral bifurcation. There were faint septal collaterals with the PDA and right posterolateral filling mainly via epicardial collaterals from the SVG-OM. A primary retrograde approach was followed. The septal collateral could not be accessed due to severe calcification. The epicardial collateral from the SVG-OM to the right PDA was challenging to cross due to tortuosity but was eventually successfully crossed using a Suoh 03 guidewire. Crossing the distal cap was very challenging. The microcatheter and guidewire became “frozen” and had to be removed losing access to the PDA. The epicardial collateral was recrossed followed by successful advancement of a knuckled Mongo wire to the RCA ostium. Using the retrograde wire as marker of the vessel location we were able to advance an Astato 20 guidewire to the proximal RCA, followed by successful guide extension reverse CART and externalization of an R350 guidewire. We tried to wire the right posterolateral but had significant difficulty due to significant calcification. We advanced a guidewire subintimally but could not deliver a Stingray balloon due to several calcification despite multiple balloon dilations of the RCA and right posterolateral. The RCA was successfully recanalized with TIMI 3 flow to the PDA and antegrade flow to the right posterolateral that was not stented (subintimal plaque modification).

[@shangz0216]

Thanks for the educative presentation.

[@TheCardio7]

Could you please share orthogonal views of SVG to LAD . Not sure if it’s “without significant disease “ . Thanks

[@praveenalane4331]

Don’t understand how could you do these complex procedures and how these patients could tolerate …when a lot of my post cabg patients complain chest pain for even angiograms …Thanx for the cases professor

[@ugurhepcivici9995]

👏👏👏

[@farukakturk5388]

Sir, will you check RCA later on? If yes when will you do a control angiogram?