PMC7201438_01
Recanalization of RCA CTO by a retrograde approach. (a) CAG showed LAD to RCA collaterals. (b) Simultaneous bilateral CAG showed long RCA CTO at bifurcation with large branches; (c) Corsair catheter in the right PDA placed retrograde via a epicardial collateral from the LAD, and tip injection showed antegrade wire in false lumen; (d) retrograde wire and Corsair into antegrade Guidezilla guide; (e) sequentially predilation RCA along antegrade RG3 wire; (f) retrograde angiography showed the severe disease in PLV.
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CAG demonstrated severe stenosis of the proximal RCA and CTO of the RCA extending from the RCA middle to the posterior descending artery (PDA) and PLV bifurcation (Figure 1(a)). The RCA distal bifurcation was well filled by CC2 septal collateral channels and CC3 epicardial collaterals from the left anterior descending artery (LAD) (Figure 1(b)). The lesion was initially approached antegradely with a Fielder XT-R wire (Asahi Intecc, Japan) supported by a Corsair microcatheter (Asahi Intecc, Japan), the Fielder XT-R could not be advanced, and composite core Gaia third wire (Asahi Intecc, Japan) was subsequently used but also failed to reenter into distal true lumen which was confirmed in false lumen by contralateral angiography (Figure 1(c)). SION guide wire (Asahi Intecc, Japan) with a Corsair microcatheter was introduced into the epicardial branch. Selective tip injection through the Corsair revealed the occlusion site at the bifurcation with large branches (Figure 1(c)). The reverse CART technique facilitated Guidezilla (Boston Scientific, Natick, MA, USA) into CTO middle segment for picking up retrograde wire and manipulating the retrograde Pilot 200 wire (Abbott Vascular, USA) and Corsair into a Guidezilla guide (Figure 1(d)). After sequentially predilation with a 1.5 x 20 mm/2.0 x 20 mm balloon along an antegrade RG3 wire (Figure 1(e)), RCA antegrade flow was restored into the PDV, but retrograde angiography showed the severe disease in the PLV (Figure 1(f)).
RCA bifurcation CTO PCI: (a) Corsair catheter in the right PLV placed retrograde via septal collaterals from the LAD and antegrade reverse bent wiring with the Crusade catheter failed into PLV; (b) recovery flow of PLV after retrograde balloon dilation; (c) IVUS showed PLV ostium had larger area before PDA stent; (d) angiography of RCA showing TIMI 1 grade flow in the right PLV after stent in the main vessel; (e) retrograde small profile balloon dilation to recovery PLV flow; (f) antegrade balloon and retrograde balloon outside the main branch stent final kissing technique; (g) the final result with flow in the right PDA and PLV; (h) IVUS showed the final PLV ostial area.
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Several attempts to wire PLV in the antegrade direction using several guide wires failed, and even "reverse bent wiring with the Crusade catheter" for a Field XT-R wire recrossing to the PLV still failed because of the retroflexed angle (Figure 2(a)). Thrombolysis In Myocardial Infarction (TIMI) 3 grade flow (Figure 2(b)). The intravascular ultrasound (IVUS) examination showed that the provisional stent from the PDV to the RCA proximal segment was appropriate with a low rate of PLV occlusion (Figure 2(c)). But angiography showed that PLV flow was slower in TIMI 1 grade flow after stents (Figure 2(d)). A retrograde 1.5 x 20 mm balloon successfully advanced through outside the PDA stent into the PLV to dilate it, and the flow was rescued (Figure 2(e)). To avoid the plaque shift to the PDA and preserve PLV flow, an antegrade 3.0 x 15 mm balloon Trek (Abbott Vascular, USA) with retrograde 2.0 x 20 mm Trek balloon performed the final kissing technique (FKT) to dilate bifurcation lesion with 14 atm, respectively (Figure 2(f)). Angiography and IVUS showed that PLV flow was successfully reserved (Figures 2(g) and 2(h)).