A 68-year-old gentleman with hypertension, and heart failure with reduced ejection refraction, complained of effort angina when he was going upstairs for one month.He denied paroxysmal nocturnal dyspnea or orthopnea. Physical examination revealed regular heart beat, no cardiac murmur, no S3/S4, clear breathing sound, and bilateral leg pitting edema, Grade 1.
1. Heart echo: Impaired LV systolic and diastolic function with LVEF = 48 % 2. Myocardial perfusion scan:The scintigraphic findings suggest severe ischemia, mostly in the LAD territory.
CAG findings: CAD with SVD
1. LAD ostium CTO, with Collateral arteries from RCA-PDA, RCA-PLV to LAD-m and LAD-d
2. J-CTO score = 3, CTO length > 60 mm
3. No visible LAD stump
1. Because of relatively difficult fromantegrade approach, we tried retro-grade approach first. We performed contralateralcoronary angiography.
2. We used 7Fr SAL-1 GC via right femoralartery, and 7Fr EBU 3.5 GC via left radial artery. Guide wire was supported byFinecross Microcatheter (MC) and Guideliner GC during retrograde approach.
3. The Wire advanced through MC but couldnot pass the distal cap. (GW: Sion à Fielder FC à Fielder XTA à Gaia second à Conquest). Besides, The retrograde route was too long, but there was no available 90cm GC in-site. Meanwhile, the patient stated to complain of chest tightness!
4. Then, we stop the procedure of retrograde approach, and then decided to try antegrade approach. Because the CTO lesion was at LAD ostium, we advanced guide wire to LCX, and use crusade MCwith GW to puncture and find the LAD entry. (Fielder FCà Gaiasecond à Conquest)
5. However, it failed due to large anglewith poor GW support. Then, we advanced GW to LAD-D1, and then used Fielder FC with crusade MC to find LAD entry successfully. The key point was the acuteangle with more GW support.
6. The GW was advanced to LAD-D, but the GWwas in subintima layer, so the GW was advanced to LAD septal branch.
7. Then, we performed POBA with 20*15 mmballoon at LAD-P and LAD-O to LM, and TIMI II flow was noted for confirming the GW was in true lumen, and then delivered Crusade catheter to LAD septal branch.
8. Again, we used crusade catheter with CTOwire doing puncture at LAD-M CTO lesion, and the GW advanced to LAD-D further, and then into another septal branch.
9. Again, we did POBA with 20*15mm balloonat LAD-M CTO lesion, and then used crusade catheter with CTO wire doing puncture at LAD-D CTO lesion.
10. After wire looping and parallel technique, the GW was advanced to LAD-D site successfully.
11. We used IVUS to check the puncture route, and there was only one site was in subintima layer, which was at LAD-Msite. After three stents was deployed at LAD to LM lesion, the LAD final angiography is optimal.
12. However, the LCX-O was jailed by LAD toLM stent, so reverse Culotte technique with POT was done for LM bifurcation lesion, and then final result was optimal.
CTO GW with microcatheter support are the basic tools for dealing with CTO lesion. However, long CTO is always difficult, especially when retrograde approach is not available. Crusade microcatheter is often applied for providing antegrade wire support, facilitating wiring of side branches, reverse wire technique, and efficient wiring of stent struts. In this case, we demonstrated a technique for providing antegrade wire support via CTO GW with Crusade MC to pass through a very long LAD CTO lesion (> 6cm) successfully and smoothly. The technique by Crusade microcatheter may has the potential to became standard technique for dealing with the LAD very long CTO lesion.