Fighting Through a Heavy Calcified RCA-CTO; Required Retrograde Approach Two Times in the Difficulty of Passing Devices Through

Transcription

1 Fighting Through a Heavy Calcified RCA-CTO; Required Retrograde Approach Two Times in the Difficulty of Passing Devices Through The Department of Cardiology Dai-ni Okamoto General Hospital Masaki Tanabe M.D. Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

2 Case. 79 y.o. female Chief Complaint Cardio Pulmonary Arrest Present Illness A 79-year-old female patient has been undergone hemodialysis due to chronic renal failure for several years. She fell into ventricular fibrillation suddenly, and was performed cardiopulmonary resuscitation. After resuscitation, coronary angiography was performed which revealed severe three vessel disease involving proximal RCA-CTO. After staged PCI to left coronary artery, she was designed CTO-PCI to proximal RCA. Coronary Risk Factors Hypercholesterolemia, Hypertension. ESRD on HD Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

3 Problems Diagnosis Silent Myocardial Ischemia, Three Vessel Disease Prior intervention BES(NOBORI 2.5/18mm) to mid LCX Prior operation DDD PMI due to CAVB CAG findings #1ostial 90%, #1distal CTO, #5 75%, #6 50%, #9 75%, #11just proximal 75%, #12 75% Collaterals ; transseptal collateral to #4PD Target Lesion proximal-rca-cto with severe calcified lesion The SYNTAX score 38 The J-CTO score 2 Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

4 Baseline Angiography; RCA RCA was occluded to proximal portion and had diffuse stenosis from aorto-ostium,with severe calcification.

5 Baseline Angiography; LCA LMT had moderate stenosis and LCX had severe stenosis at the bifurcation of LMT. Fair transseptal collaterals were shown to distal RCA. RCA was dyed by contrast media till mid portion retrogradely.

6 Baseline Angiography; LCA LMT had moderate stenosis and LCX had severe stenosis at the bifurcation of LMT. Fair transseptal collaterals were shown to distal RCA. RCA was dyed by contrast media till mid portion retrogradely.

7 System; PCI to proximal RCA-CTO;1 st attempt bilateral transfemoral approach guide catheter : AL1.0 ST SH(+) 7Fr Axess to RCA SPB 3.5 SH(+) 7Fr Avess to LCA guide wires : Sion blue, Sion, Fielder FC, SUOH, Fielder XT, Ultimate bros3 2, Conguest pro, RG3 Microcatheter; Corsair 135cm & 150cm, Tornus Pro. 2.1Fr Sapphire II 1.0 5mm, Sapphire II mm, Tazuna mm, Trek RX mm, Lifespear mm, Ikazuchi X hyper 1.5 9mm Signet NC mm Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

8 At first, PCI to RCA-CTO was started by antegrade approach. However, some guiding catheters could not engage stably because of severe stenosis with heavy calcification from aorto-ostium. Moreover, it was difficult to maintain coaxial position of guiding catheter due to anterior take-off of RCA ostium. PCI to proximal RCA-CTO; Antegrade approach XT-R with the Corsair microcatheter

9 Retrograde wiring via the first transseptal collateral(1) As a result, this PCI to RCA-CTO was required for changing procedure with retrograde approach, in spite of having moderate stenosis of LMT

10 Retrograde wiring via the first transseptal collateral(2) Retrograde wiring was started by the Sion with the Corsair microcatheter support via a transseptal collateral channel, successfully reached the mid RCA from 1 st septal branch.

11 Retrograde the severe calcified CTO lesion Retrograde wire was exchanged to the Ultimate the severe calcified CTO exit.

12 Retrograde wire direct cross through the severe calcified CTO lesion Retrograde wire (which was exchanged to the Ultimate bros.3 from the CTO exit) could directly pass all through the CTO, and luckily rendezvoused in spite of the un-coaxial position of the antegrade guiding catheter.

13 Retrograde Corsair was braided and damaged!! However, the calcification within the CTO was so heavy that the Corsair microcatheter could not pass through. Consequently, the Corsair s tip was damaged,braided, and trapped the wire shaft by too much rotating and too much pushing.

14 Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan Warnings and Cautions!! Be careful when using ASAHI Corsair in cases with calcification or crossing stent struts. Do not advance or rotate ASAHI Corsair if the tip is trapped or impacted; doing so may lead to damage to the coating, tip, or braiding of ASAHI Corsair. Never accumulate the torque power for one direction. Braided tip; visual exam and x-ray

15 Start of antegrade wiring as buddy wire technique For the purpose of trouble shooting procedure, antegrade wiring was ongoingly started by the Conquest pro. with the combination of another Corsair microcatheter, under the situation of balloon anchoring of retrograde wire tip intra guiding catheter.

16 Antegrade wire cross as buddy wire technique Eventually, antergrade wire using the Conquest pro. was navigated to the distal true lumen under the merkmal of the retrograde wire route. Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

17 Retrieval of retrograde wire system!! Fortunately, the braided Corsair was retrieved without vessel/channel injury. The CTO-PCI to proximal RCA was continued by antegrade approach after retrieving these retrograde devices. Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

18 Any Device unpass through antegradely Balloon Tornus pro. 2.1Fr However, minimal sized balloon(saphire II 1.0/5mm) cound not pass through the heavy calfcified lesion within the CTO. A next procedure to solve ; drilling of the Tornus catheter was attempted, but, could not done well, too.

19 Any Device un-pass through antegradely with buddy wire technique balloon Using Slender system As a next procedure to solve, buddy wire method using another wire(the Ultimate bros.3) cross and usage of slender device (009 inch wire with the combination of 1.5/9mm Ikazuchi X hyper balloon) were attempted, but, both could not done well, too. Finally this CTO-PCI to proximal RCA 1 st attempt was unsuccessful in device un-pass through.

20 the 2 nd attempt Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

21 System; PCI to proximal RCA-CTO;2 nd attempt bilateral transfemoral approach guide catheter : AL1.0 ST SH(+) 7Fr Axess to RCA SPB 3.5 SH(+) 7Fr Avess to LCA guide wires : Sion blue, Sion, SUOH, Fielder XT-R, Ultimate bros3, Conguest pro, RG3, Microcatheter; Corsair 135cm & 150cm, Amplatz Gooseneck Snare 10mm, Soutenir 7mm 3mm Ikazuchi X hyper 1.5 9mm, Ikazuchi X hyper mm, Lifespear mm, Ikazuchi X mm NC Trek mm, Douvan mm NOBORI 3.0 8mm, NOBORI mm Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

22 Retrograde wiring via the first transseptal collateral(1) PCI to CTO 2 nd attempt was started by retrograde approach first for judging difficult situation of antegrade approach and the consequence of the 1 st attempt. Retrograde wiring was performed by the Sion and the Sion blue with the Corsair microcatheter support via the 1st septal collateral channel that passed through at the 1 st PCI attempt, however this route became misty and was inapplicable to pass through because of shrinkage of channels.

23 Retrograde wiring via the 3 rd transseptal collateral Thus, wire surfing to other septal branches was required. Eventually, retrograde wiring was succeeded by the SUOH with the Corsair microcatheter from 3 rd septal branch, and reached the distal RCA.

24 PCI to proximal RCA-CTO etrograde Corsair s tip could not progress anymore due to heavy calcification After retrograde wire was exchanged to the Ultimate bros.3 from the CTO exit, the Corsair microcatheter was followed the wire tip. However, as expected, the Corsair s tip could not progress anymore at the position of heavy calcified lesion within the CTO.

25 Retrograde wire direct crossing using the RG3 As next step, retrograde wire was exchanged to the RG3 at this point. Consequently, the RG3 was passed all through the CTO, and came at ascending aorta directly (the wire tip could not put into un-coaxial antegrade guiding catheter).

26 Advance to retrograde the abdominal terminal aorta The RG3 wire tip was pushed forward to the terminal aorta antergradely, and was caught by the 10mm Gooseneck snare and the 3.0mm Soutenir, and brought into the antegrade guiding catheter at this point. Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

27 Re-insertion of antegrade guiding catheter following retrograde wire Continuously, the antegrade guiding catheter was re-inserted to the RCA ostium with navigation by the RG3 shaft. As the result, wire externalization was completed, i.e. wire round heart situation was perfectly completed.

28 Minimum attacking balloon passed through with the condition of wire round heart situation!! PCI to RCA-CTO was continued by antegrade approach. Because strong back-up force was obtained by wire round heart situation, the minimum attacking balloon (Ikazuchi X hyper 1.5/9mm) could managed to cross all through the CTO segment beyond heavy calcified lesion. But, the balloon was easily ruptured!!

29 POBA Moreover, other two balloons were ruptured, too!! a After trying balloon dilatation with some kinds of balloons, finally, balloon dilatation was succeeded in. Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

30 Stenting NOBORI 3.0/8mm NOBORI 3.0/14mm Two BES(Biolimus Eluting Stent)s were deployed from RCA orifice to the end of the CTO lesion.

31 Final result Finally, successful revascularization was attained to the proximal RCA-CTO lesion. Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan

32 Catheterization Laboratory, Department of Cardiology, Dai-ni Okamoto General Hospital, Kyoto, Japan Summary Heavy calcification in the CTO segment triggered the braided and damaged Corsair s tip and caused difficulty to pass any device through. Retrograde direct crossing with RG3 and strong back-up support after wire externalization using catching technique were helpful as the bail-out procedure in these situations.