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

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

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

4. 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

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

6. 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)

7. 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

8. Baseline Angiogram

9. Baseline Angiogram

10. Baseline Angiogram

11. Baseline Angiogram

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

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

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

15. MSCT “parallel“ viewing

16. MSCT: Orthogonal roadmap

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

18. Identifiying the entry

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

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

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

22. Gradual advancement of Fielder XT

23. Verified distal intraluminal position

24. 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

25. Difficulties in balloon passage: anchoring

26. Post dilatation

27. After 2 Xience stents

28. 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 X 12 (Abbott Vascular)

29. 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

30. 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