Slide 1

P.R., 58 y, F

Previous Medical History: Hypercholesterolaemia, Hypertension, Family history of CAD, One year before pt developed CCS Class 2 Angina: angiography showed SVD with previous failed attempt of recanalisation (anterograde and retrograde)

Medication: Bisoprolol 10 mg od, Isosorbide Mononitrate 60 mg od, Nicorandil 30 mg bd, Lansoprazole 30 mg od, Lisinopril 5 mg od, Aspirin 75 mg od, statin intolerance

ECG: SR 68 bpm with normal tracing

Blood test: Hb 131 g/L, PLT 214 10^9/L, INR 0.9, Creatinine 65 mmol/L, GFR 81 mL/min, Cholesterol 5.5 mmol/l

Echocardiogram: LV normal size, hypokinetic inferoposterior wall. EF 55%

Carlo Di Mario, Roberta SerdozRoyal Brompton HospitalImperial College London, UKBranch Occlusion in CTO Recanalisation

No Stump, 5 cm long Occlusion ending in Bifurcation,Werner 1 Septal Coll.

Previous Unsuccessful attempt anterograde and retrograde (distal vessel not reached)Bifemoral approach with 45 cm femoral sheats 7 Fr EBU 4.0 8 Fr JR 4.0

Confianza 12 was used to penetrate the proximal capFurther progress with a Gaia Second wire supported by a Corsair 135 cm.

ANTEROGRADE APPROACH

Multiple wires did not enter the distal cap

Sion wire reached the occlusion distal cap; Corsair skrewed trough the collateral branch

RETROGRADE WIRING (fourth collateral attempted)Tip injection

ANTEROGRADE CROSSING: NO REVERSE CART NEEDEDUltimate wire enters the 3rd segment of the RCA. Retrograde Corsair withdrawn to start reverse CART but the anterograde Ultimate easily enters the PDA with intraluminal position confirmed by tip injection and soft wire insertionResolute Integrity 3.0/38 mm positioned with retrograde injection

DES Implantation in mid RCAResult after stent

NC Sprinter 2.0/25 mm

Dissection in PDAResolute Integrity 2.25/30 mmin position

Non ci sono altre immagini, solo pallone gonfio.7

The Ultimate wire supported by a Corsair that entered the dissected PL branch; wire is exchanged for a Fielder XT wire that reaches the distal vessel under retrograde injection forming a small loopPL branch wiringTip injection confirms the intraluminal position of the Corsair

Resolute Integrity 2.25/26 mm in PL branch

Kissing Balloon with Stent Delivery Balloon & 3.0/12 mm in main vesselDES implantation in PL branch

Final result with wires in placeKissing Balloon with 1.5 /15 & 2.0/25 mmSecond wire into another terminal branch of PL

Final Result

ConclusionThe reconstitution of the distal RCA at the crux is one of the most difficult targets for anterograde recanalisation

Retrograde approach is favoured when feasible but does not ensure salvage of both branches

Creative solutions involving subintimal wiring can be preferrable to the persistance of occlusion of part of the original target vesselBranch Occlusion in CTO Recanalisation