Case 249: Manual of CTO PCI - Left main CTO PCI

A patient was referred for PCI of a left main CTO after experiencing recurrent failure of a saphenous vein graft to the ramus. The CTO had a blunt but clear proximal cap, length of 20 mm, a bifurcation at the distal cap (ramus and circumflex) with the ramus filling via a SVG that had recurrent restenosis. Antegrade wiring with a Hornet 14 resulted in extraplaque wire position. After balloon angioplasty of the restenotic segment of the SVG a Gaia Next 3 wire successfully crossed the CTO into the proximal true lumen and was advanced into the antegrade guide catheter. After wire externalization the left main CTO was predilated and stented into the LAD but the stent was severely under-expanded. Intravascular lithotripsy was not successful in expanding the stent but a SIS-OPN balloon was successful at 45 atm. The ostium of the circumflex became compromised with a dPR of 0.34. The circumflex was predilated and stented using the culotte technique with a nice final result. In the end the SVG to the ramus was occluded with a combination of an Amplatzer vascular plug and a Penumbra packing coil.

[@drpetersuveges]

Really awesome case! If you don’t mind, could you tell us if there’s a threshold to the flow or residual stenosis when you decide not to close the SVG? Now there’s a nice final result, but if there’d remain a still significant looking lesion would you leave the graft open maybe measure the residual stenosis with FFR or check the MLA and then decide? Thank you!

[@manosbrilakis]

Great point - hard to quantify the SVG flow, but in general if there is significant competitive flow in the native vessel from SVG flow we tend to occlude the SVG. If the graft has severe lesion(s) with TIMI 2 flow, we generally let it occlude spontaneously.

[@drpetersuveges]

@@manosbrilakis thanks again! 😊

[@rohinsaini4]

Wow

[@soi2238]

Excellent case! But what was the reason to leave the Final POT step after KBI?

[@manosbrilakis]

Great point - we should do POT after kissing balloon inflation (unless possibly if IVUS shows a great result)

[@이세환-b6r]

👍

[@shangz0216]

Thanks for the excellent case presentation.

[@praveenkumarh7089]

Absolutely marvellous results 👏👏

[@drnohayaseen]

.