Successful revascularization of LCX-CTO via a underlying
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1 IPS/CTO LIVE 2012 Asan Medical Center, Seoul, Korea Successful revascularization of LCX-CTO via a underlying collateral l channel The Department of Cardiology, Daini i Okamoto general hospital Masaki Tanabe M.D. Takeo Kunitomo M.D. Hiroyuki Mizuno M.D. Takafumi Yagi M.D. Ms.Nanase Suyama
2 Case. 78 y.o. male Target Lesion: proximal LCX CTO (the 2 nd attempt) Diagnosis: AP, post CABG Past History: CABG(LITA-LAD LAD, SVG-D1&OM)(1998), P-C C.I., P-PMI, P-VP shunt Prior intervention: PCI to proximal to mid RCA ( Cypher 2)(2005) PCI to distal RCA ( Cypher ) other hospital PCI to proximal LCX CTO (the 1 st attempt) ; unsuccess due to GW uncross by antegrade approach Coronary Risk Factor: DM,HTN,CKD, Final CAG findings : RCA ; mid RCA :in-stent restenosis(+), AV node branch CTO, LMT ; moderate stenosis, proximal LAD ; severe stenosis, proximal LCX ; CTO, LITA - LAD patent, t SVG - D1 & OM patent (OM branch was proximal site)
3 control CAG
4 control CAG
5 control CAG
6 PCI to the proximal LCX-CTO (the 1 st attempt) Antegrade approach Parallel wire technique Formation of huge dissection
7 To the end that leads to succeed in revascularization on the 2 nd attempt IVUS guided PCI by antegrade approach might better perform on the 2 nd attempt. Bilateral approach, if possible. That is, if there exist a applicable channel for retrograde approach,
8 Review the collateral channel from CAG(1) This angiography doesn t seem to be epicardial channel from LAD distal to LCX via LV apex
9 Review the collateral channel from CAG(2) Epicardial channel from D1 and OM via SVG to LCX were found. However, these appeared inapplicable to retrograde approach because of severe tortuosity.
10 Review the collateral channel from CAG(3) A Competitive flow was detected at the atrial circumflex(ac) branch via retrograde flow of LCX from SVG to OM branch.
11 Review the collateral channel from CAG(4) The flow of AC branch was competed with somewhere
12 Review the collateral channel from CAG(4) The flow of AC branch was competed with somewhere
13 Review the collateral channel from CAG(5) The competitive flow made its way toward distal RCA, but, that flow had not been up to RCA
14 Review the collateral channel from CAG(6) The imperceptible collateral was found from sinus node artery toward LCX, which might be barely continuity to distal LCX.
15 As a end result, these all collaterals appeared inapplicable to retrograde approach in this situation...
16 However it was expected that the competitive flow might reflect underlying connection as atrial channel via AV groove.
17 preceding revascularization to the CTO-PCI of contralateral artery ( i.e. the distal RCA-CTO of AV node branch) might change this situation...
18 PCI to RCA (in-stent restenosis & #4AV-CTO)
19 PCI to RCA (in-stent restenosis & #4AV-CTO) Antegrade wire cross Corsair + Fielder XT
20 PCI to RCA (in-stent restenosis & #4AV-CTO) POBA(1) 2.0/15mm Tazuna
21 PCI to RCA (in-stent restenosis & #4AV-CTO) POBA(2) 3.5/15mm NC Voyager
22 Final PCI to RCA (in-stent restenosis & #4AV-CTO) The Collateral via AV groove (from RCA AV branch to LCX AC branch) came out clearly!!
23 PCI to the proximal LCX-CTO (the 2 nd Attempt) p)
24 PCI to the proximal LCX-CTO (the 2 nd Attempt) retrograde approach Corsair + Sion blue the collateral channel via AV groove(lcx AC to RCA AC)
25 PCI to the proximal LCX-CTO (the 2 nd Attempt) retrograde approach tip injection Corsair + Sion blue
26 PCI to the proximal LCX-CTO (the 2 nd Attempt) retrograde wiring bilateral approach (Sion blue Fielder FC) Antegrade wire(fielder XT) was easily crossed into the subintimal space that had made by the 1 st attempt PCI.
27 PCI to the proximal LCX-CTO (the 2 nd Attempt) Reverse CART Fielder FC 2.0mm Tazuna balloon inflation to #11-#13 antegradely into subintimal space
28 PCI to the proximal LCX-CTO (the 2 nd Attempt) Stenting Xience V 3.5/15mm+Xience V 2.5/18mm
29 PCI to the proximal LCX-CTO (the 2 nd Attempt) Final
30 Conclusion cuso It was predicted that the collateral of atrial channel via AV groove was underlying in exact detail of these control angiographies. Due to preceding revascularization to CTO of contralateral artery( i.e. the distal RCA-CTO of AV node branch), the latent atrial channel became clear. It brought about success in the target vessel revascularization (the proximal LCX-CTO) that bilateral approach was applicable to the clarified atrial channel via AV groove.
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