LAD CTO PCI: Hybrid approach in proximal cap ambiguity

Operators:Assoc. Prof. Dr. Mutlu Vural

Bağcılar Education and Research Hospital

Case Summary

A 77-year-old male patient with effort dyspnea, dizziness and generalized deterioration is undergone coronary angiography by another operator. I have planned the LAD KTO procedure with a hybrid approach. EF was 60% on ECHO.


Before the procedure, a severe tortuosity was detected in the right groin, but long sheath was not available (Video 1). The right coronary artery was cannulated with the AR-2 guiding catheter from right femoral artery and the left coronary artery was cannulated with the left coronary 6 Fr JL 4.0  guiding catheter and double injection was performed (Video 2). The primary retrograde was first attempt because of the ambiguity of the proximal cap. The caravel microcatheter was advanced into the PDA with the workhorse wire. Retrograde septal collateral  crossing into LAD was unsuccessful and antegrade approach was attempted before trying to cross two epicardial collaterals (Video 3). The microcatheter was inserted into the first septal branch via the soft wire to advance the Conquest Pro 12 to punture the proximal cap. The true-true lumen puncture was attempted by gentle manuevers (Video 4). After verifying with the orthogonal two images, the tip injection was done after advancing the microcatheter (Video 5). The wire was exchanged and the microcatheter was withdrawn by trapping. Severe curvature and accordion effect was observed in the groin when trying to deliver balloons ( Figure 1). Right coronary catheter was introduced into left iliac artery with 0.035  guide wire. The delivery of a CTO balloon and the 1.5 balloon were still difficult. On top of that, an extrasupport buddy wire was introduced and the delivery of equipments were relatively easy (Video 6). Dilated with a 2.5×12 balloon ( Figure 2). After 2.5×30 and 2.75×18 mm DES stents and optimization with the 2.75 stent balloon, final result was satisfactory (Video 7 and Video 8).

Home messages:

  1. Femoral long sheaths should be used in CTO PCI.
  2. It is not easy to fall into the LAD with multi-branched RCA through septal collaterals.
  3. An antegrade approach should be attempted before epicardial collateral crossing attemps.

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Figure 1

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