Case Report

Retrograde CTO Crossing Through Torturous Epicardial

Nelson Lim Bernardo, MD, Co-Director, Coronary CTO Program, Medstar Washington Hospital Center, Medical Director, Peripheral Vascular Laboratory, MedStar Heart Institute; Director for Peripheral Intervention, Cardiovascular Research Institute, MedStar Research Institute; Assistant Professor, Division of Cardiology, Medical College of Virginia campus of Virginia Commonwealth University School of Medicine; Robert Anthony Gallino, MD, Co-Director, Coronary CTO Program, Medstar Washington Hospital Center, Washington, D.C.

Nelson Lim Bernardo, MD, Co-Director, Coronary CTO Program, Medstar Washington Hospital Center, Medical Director, Peripheral Vascular Laboratory, MedStar Heart Institute; Director for Peripheral Intervention, Cardiovascular Research Institute, MedStar Research Institute; Assistant Professor, Division of Cardiology, Medical College of Virginia campus of Virginia Commonwealth University School of Medicine; Robert Anthony Gallino, MD, Co-Director, Coronary CTO Program, Medstar Washington Hospital Center, Washington, D.C.

This is a 62-year-old white female with coronary artery disease (CAD) referred for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The patient presented with angina pectoris. Stress MPI-study done was positive for ischemia. Coronary angiography was performed and demonstrated a CTO of the mid left anterior descending (LAD) coronary artery. Left ventricular (LV) systolic function was well preserved with normal LV ejection fraction (EF).

An 8 French (Fr) Extra Backup (EBU) 3.5 (Medtronic) was used to engage the left system.  A 6 Fr Judkins Right (JR) 4 guiding catheter (Cordis) was used to engage the right coronary system.  Dual injections were then performed (Figure 1). Attempts to cross the totally occluded mid LAD segment in the antegrade fashion using a Fielder XT (Abbott Vascular) were unsuccessful. Wires used in the antegrade approach were an .014 Asahi Fielder XT, Asahi Confianza Pro 12 (Abbott Vascular), and Pilot 200 (Abbott Vascular) through a Micro 14 ES catheter (Roxwood Medical). It was decided to proceed with the recanalization using the retrograde approach. A right ventricular (RV) branch feeding an epicardial collateral vessel to the distal LAD segment (Figure 2) was used to advance a Micro 14 catheter over a Sion guide wire (Asahi Intecc). Once advanced into the LAD, the wire was exchanged for a Pilot 200 guidewire and this was successfully advanced retrograde across the CTO into the mid LAD segment (Figure 3).  

The guidewire was then advanced into the left coronary artery (LCA) guide catheter followed by the Micro 14. Once the Micro 14 was in the LCA guide catheter, the Pilot 200 wire was exchanged for an RG3 wire (Asahi Intecc). The RG3 was externalized and the remainder of the procedure was completed in the antegrade manner. Intracoronary stenting with a 2.5 x 38 mm drug-eluting stent (DES) was performed. The final angiogram showed excellent dilatation of stenotic segments with no significant residual stenosis. 

Disclosure: Dr. Nelson Lim Bernardo reports he is a consultant for Abbott, Spectranetics, Medtronic, Boston Scientific, and Cardiovascular Systems Inc. Dr. Gallino reports no conflicts of interest regarding the content herein.