Interesting Case Review Gerald S. Werner, MD PhD Klinikum Darmstadt Darmstadt, Germany

Gerald S. Werner, MD, PhD I have no real or apparent conflicts of interest to report.

PCI – CTO of the RCA Female T.N. Age 62

CTO of the RCA Female, T.N., 62 Diagnosis 3-vessel disease - CTO of RCA - Subtotal occlusion of the LCX - Multiple stenosis of LAD branches Risk factors Diabetes mellitus Typ1 (for 40 years) Ex-smoker

Clinical presentation typical chest pain during climbing of stairs and shortness of breath during activity ECG ST-depression and negative T in V5 & V6

Non-invasive evaluation Echo: Hypokinesia basal wall, LV function <50% Stress-ECG: 150 W significant ST changes MRI perfusionscan EF 41% Hypokinesia lateral and inferolateral, anterior and septal inferolateral ischemia Subendocardial late enhancement in the territory of all vessels (25-50% in various territories)

Laboratory investigations Hb = 12,5 g/dl Creatinine = 0,8mg/dl Creatinine clearance = 77 ml/min Cholesterol (total) = 192 mg/dl HDL = 91 mg/dl LDL = 69 mg/dl on therapy HBA1c 6,4% CK 371 U/l Troponin I <0,04 ng/ml

Baseline Angiogram

Baseline Angiogram

Baseline Angiogram

Baseline Angiogram

Risk evaluation EuroSCORE (mortality logistic) = 2,25% Syntax score = 19 Surgeon declined CABG because of poor peripheral targets

Key issues / Strategy PCI of RCA as most important territory and most difficult lesion LCX as secondary territory, but with proven ischemia

Key issues / Technique Difficult identification of RCA occlusion site on diagnostic angio The potential of MSCT coregistration for the planning of the technical approach

MSCT “parallel“ viewing

MSCT: Orthogonal roadmap

Material Guide: AR1 SH 7Fr (Launcher, Medtronic)

Identifiying the entry

Where is the CTO, and how long ? No calcium at proximal cap and side branch, but at distal cap.

Material Guide: AR1 SH 7Fr (Launcher, Medtronic) Microcatheter: Finecross (Terumo) Initial wire: Fielder XT (ASAHI Intecc)

Even a Fielder XT can penetrate a cap A Fielder XT is NOT a 30s wire

Gradual advancement of Fielder XT

Verified distal intraluminal position

Material used Guide: AR1 SH 7Fr (Launcher, Medtronic) Microcatheter: Finecross (Terumo) Initial wire: Fielder XT (ASAHI Intecc) Balloon: MiniTrek 1.2 X 12 (Abbott Vascular) Anchoring: BMW wire + Maverick 2 x 15 mm

Difficulties in balloon passage: anchoring

Post dilatation

After 2 Xience stents

Material used Guide: AR1 SH 7Fr (Launcher, Medtronic) Microcatheter: Finecross (Terumo) Initial wire: Fielder XT (ASAHI Intecc) Balloon: MiniTrek 1.2 X 12 (Abbott Vascular) Anchoring: BMW wire + Maverick 2 x 15 mm Predilatation: Maverick 2.5 X 30 mm (BSC) DES: Xience Prime LL 2.5 X 38 + 2.5 X 12 (Abbott Vascular)

Procedural details Lab time: 134 min (taped case recording) Fluoro time: 37.9 min Contrast volume: 230 ml Precautions: 500 ml NaCl infusion during procedure

An interesting case because … … demonstrates the need for careful angio analysis …, assisted by additional MSCT visualization MSCT demystified the CTO in this case A Fielder XT does not need “microchannels“ to work well Anchoring is a basic and cheap technique