PMC6232790_01
Angiography after the compensation of heart failure reveals severe stenosis with heavy calcification of the left anterior descending artery, chronic total occlusion of the left circumflex artery (a), and hypoplasty of the right coronary artery (b).
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Angiography after compensated heart failure revealed hypoplasty of the right coronary artery, severe stenosis with heavy calcification of the LAD, and CTO of the LCX (Figure 1).
Angiographies before and after the percutaneous coronary intervention to the left anterior descending artery.
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We first treated the LAD with standard stenting (Figure 2).
(a) Computed tomography after successful revascularization of the left anterior descending artery; the short and mildly calcified chronic total occlusion of the left circumflex artery; a stump presents after sending out the small branch (yellow arrows). (b) The middle left circumflex artery is occluded with Rentrop grade 2 collateral flow from the posterolateral branch channel and the apical channel. AP: antero-posterior; CRA: cranial; LAO: left anterior oblique.
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Computed tomography after successful revascularization of LAD revealed a short and mildly calcified CTO; and a stump was revealed after sending out the small branch (Figure 3(a)). The middle LCX was occluded with a Rentrop grade 2 collateral flow from the posterolateral branch channel and the apical channel (Figure 3(b), Videos 1-2).
The antegrade approach with tapered wire (a) and stiff wires using the parallel wire technique (b) results in subintimal wiring.
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However, stiff wires and the parallel wire technique resulted in subintimal wiring (Figure 4). Then, we tried the chasing wire technique, pushing the antegrade wire and pulling the retrograde wire simultaneously (Figure 7, Video 4).
(a) Tip injection reveals the connection from the apical channel to the posterolateral branch. (b) The bidirectional angiography shows the short chronic total occlusion length. (c) The Gaia 2nd directly crosses the chronic total occlusion lesion. (d) The intravascular ultrasound imaging confirms that the retrograde wire is in the true lumen.
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Tip injection revealed that the apical channel was connected to the posterolateral branch (Figure 5(a)). Intecc) passed the channel and bidirectional angiography revealed the short CTO length (Figure 5(b)), and the Gaia 2nd (ASAHI Intecc) directly crossed the CTO lesion (Figure 5(c)). Intravascular ultrasound imaging confirmed that the retrograde wire was in the true lumen (Figure 5(d)).
The wire rendezvous technique. (a) The insertion of the retrograde Gaia 2nd into the antegrade Corsair Pro. (b) The antegrade Corsair Pro advance in the chronic total occlusion, tracking on the retrograde guidewire, but cannot pass the chronic total occlusion completely. The arrowheads indicate the tip of the Corsair Pro. The arrows indicate the tip of the retrograde Gaia 2nd.
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Therefore, we performed the rendezvous technique that meant full insertion of the retrograde Gaia 2nd into the antegrade Corsair Pro (Figure 6(a), Video 3). The antegrade Corsair Pro could advance into the CTO, tracking on the retrograde guidewire, but could not pass through the CTO completely (Figure 6(b)).
The chasing wire technique, pushing the antegrade guidewire and pulling the retrograde guidewire simultaneously. The arrowheads indicate the tip of the Corsair Pro. The arrows indicate the tip of the antegrade SION black. The arrows indicate the tip of the retrograde Gaia 2nd.
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Then, we tried the chasing wire technique, pushing the antegrade wire and pulling the retrograde wire simultaneously (Figure 7, Video 4).