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Aortic dissection and radial rupture during retrograde CTO PCI: Management of complications

Operators:Operator: Prof.Dr.Şevket Görgülü,
Cath Lab Nurse: Buse Taşdemir
Cath Lab Technician: İsmail Topaç

Acibadem University of Medicine, Kocaeli Acibadem Hospital

Procedure

The patient underwent dual injection from double-radial access for retrograde RCA CTO PCI. The right radial 7Fr EBU guide catheter was inserted into the left system and the 6 Fr right judkins guide catheter was inserted into the RCA (Video 1). Retrograde Corsair and Sion blue wire were introduced into the first septum and a tip injection was performed (Video 2). Sion wire was used for surfing and finally it was decided to try the 2nd septal by going out of the vessel (Video 3, Video 4 and Video 5). After the tip injection, a new Sion wire was taken down to the distal PDA and the wire was introduced at the extreme end to deliver the Corsair (Video 6, Video 7). After transferring to Corsair, peripheral 0.14 gladius CTO was exchanged based on excessive calcification and dissection to prepare for reverse CART in the middle of RCA (Video 9 and Video 10). Corsair was further advanced with Gaia 3rd and attempted antegrading with antegrade Corsair and Conquest pro (Video 11 and Video 12). The patient could not continue due to severe left arm pain and chilling and cooling. The sheath was squeezed and the arm was pushed down and the femoral puncture was attempted. However, due to the absence of femoral pulses,  6 Fr left Amplatz 2 was reintroduced to support the rupture radial transition with soft slippery wire (Video 13). However, a large dissection has developed in the RCA as well as the PDA. Antegrade opaque was not given for possible rupture. With this dissection, we could promote antegrade Corsair (Video 14 and Video 15). Antegrad knuckled Gladius 0.14 crossed to the subintimal area, Fielder XT could not enter antegrade catheter and placed in aortic dissection (Video 16). Antegrade dissection was continued with a 2×30 mm balloon for reverse CART procedure (Video 17). Retrograde with Gaia 3, introduced into the RCA catheter and trapped with a 2×20 balloon, and transported into the Corsair (Video 18). The guide catheter was removed and a type injection was made for the true lumen confirmation of Corsair in the aorta (Video 19). The Fielder FC wire was thrown into the aorta and caught with a snare and trapped in a Corsair catheter (Video 20 and Video 21). Changed to Fielder FC with RG3 (Video 22). Predilatation with 2×30 balloons (Video 23). 2.5×48 DESwas adjusted  distalLY by contrast with the left system. We were careful not to give opaque from RCA (Video 24). When a 2.75×38 drug stent is placed in the proximal, aortic retention of the opaque material implies that aortic dissection is limited (Video 25). RCA’s final image after the last stenting (Video 26 and Video 27). For the prevention of the left main coronary and collateral dissection, RG3 was pulled back with Corsair.

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