Case 231: Manual of CTO PCI - Double Stingray + DK crush

A patient was referred for PCI of an LAD CTO - a large diagonal was likely originating within the occluded segment. Antegrade wiring was attempted but the wire entered the extraplaque space. Using a Stingray with the stick and swap technique the LAD was successfully re-entered. We could not determine the origin of the diagonal despite of using IVUS because of calcification. We used the BASE technique (balloon-assisted subintimal entry) and were able to advance a wire extraplaque in the diagonal. We used the Stingray again in the diagonal and successfully re-entered. The LAD/diagonal bifurcation was successfully stented using the DK crush technique. There was poor flow in the LAD distal to the stent, that improved after prolonged balloon inflation.

[@shangz0216]

Thanks for the excellent case sharing.

[@NikhilJha89]

Why not lima to lad?

[@ivankoshkin837]

Thanks for the great case! I would have placed the first stent distal to hematoma after recanalization of the LAD so to stop its' spreading due to contrast injection and then deal with the diagonal CTO. And I would have performed the final IVUS to see the residual dissection and decide on stenting based on its' significance. Thanks again for sharing.

[@IVAN3000]

why not lima to lad

[@drroaaccu]

Why not Lima and SVG to lad and diag
Distal dissection need to be stented?
Good case

[@manosbrilakis]

Great points - surgery is a great option in patients who are good surgical candidates and agree to proceed. We could have placed additional stents but did not because flow was good and did not want to stent extensively in the LAD in case the patient requires CABG in the future.