Retrograde PTCA to LAD CTO - Case by Dr Vikrant V Vijan

Percutaneous coronary intervention for Chronic Total Occlusions (CTO) is technically challenging and comprises of 5-10% of all PCI procedures. Various studies have demonstrated that successful CTO PCI reduces the need for CABG, relieves angina, improves left ventricular ejection fraction and long-term survival.

In our case, we did PCI for a 42 years male. Patient had no risk factors. He gave a history of old anterior wall STEMI, thrombolysis in outside the hospital.

Came to us for CAG after a month in view of class 2 effort angina. Coronary Angiogram revealed triple vessel disease with critical proximal RCA lesion, 80% OM lesion and long CTO LAD lesion. The option of multivessel PCI and CABG were given and patient opted for Multivessel PCI.Initially we did PTCA to critical proximal RCA lesion followed by the attempt to cross LAD CTO lesion.We upsized from Fielder to provia 3 wire but patient had a proximal LAD dissection from CTO entry point and we decided to stop the procedure at this point.

The patient was asked to review after 6 weeks but he came back after 3 months with worsening angina. Check angiogram showed patent proximal RCA stent with persisting LAD dissection. This time we decided to go retrograde. We took bifemoral access. RCA cannulated using short AL1 7 Fr guide and LAD cannulated using 7 Fr EBU guide.

Sion blue wire was passed over corsair pro microcatheter through RCA. Initially tried to cross 2 distal septal collaterals but could not advance and finally advanced in third attempt through septal collateral. At one point corsair pro could not advance hence we used caravel microcather and succeeded in crossing through.After advancement, we exchanged sion for RG3 wire and externalised and antegradely pre dilated proximal LAD multiple times.

Over LAD fielder wire we passed 2 long DES (Tetrilimus 3 * 40 and 2.5 * 44) to LAD with good result and we stented the OM as well using 2.5 * 28 mm Tetrilimus DES.

It took us 3 hours to complete the procedure with 250 ml of contrast but the result was really rewarding. Retrograde PCI forms a very complex group of PCI intervention which requires a lot of skill and patience and should be ideally be done by experienced operators With the availability of newer hardware like microcatheters and wires the success of such complex procedures have increased.