Dual Lumen Catheter assisted Retrograde CTO Intervention

Dr. Raymond Chi-yan FUNG, Dr. Ivan TSANG

Princess Margaret Hospital, Hong Kong

A 59-year-old male presented with exertional chest pain. He had a background of diabetes mellitus, hypertension and hyperlipidaemia. Treadmill was positive for ischaemia. His left coronary angiogram showed proximal LAD chronic total occlusion (CTO) with ambiguous stump (Figure 1). The CTO was calcified with two epicardial retrograde collaterals coming from conus and a few faint septal channels coming from PDA (Figure 2).

LM was engaged with 7F EBU 3.5 guide. Ramus was wired with Run-through NS. IVUS guided proximal cap puncture was performed with Sasuke dual lumen catheter. Fielder XTA failed to find any microchannel. The proximal cap was successfully punctured with Conquest Pro 8/20 (Figure 3). Guidewire entry position was confirmed to be intraplaque by IVUS. The Conquest pro 8/20 guidewire was advanced further into CTO body before the Sasuke was exchanged to Turnpike spiral microcatheter. The Conquest Pro 8/20 was noted to be outside the vessel architecture (Figure 4). Attempt to do single wire redirection with Gaia 2nd was unsuccessful. Wire was exchanged to Pilot 200 for knuckle wiring. It only resulted in a large subintimal space but failed to cross the distal cap.

RCA was then engaged with 7F AL 0.75 guide. RCA was wired with run-through NS supported by Turnpike LP. Wire was exchanged to Sion but failed to cross the septal channel (Figure 5). The conus branch was wired with Sion wire. The more distal conus branch was attempted but failed because of tortuosity. The more proximal conus branch was wired with Fielder XTR and then Souh 3 supported by Turnpike LP (Movie 1). Retrograde puncture of LAD CTO distal cap from this collateral was extremely difficult because of the angulations and the proximity of the channel to the distal cap (Movie 2). Eventually the retrograde Sion was wired into distal LAD and the Turnpike LP was exchanged to Sasuke dual lumen microcatheter. The LAD distal cap was successfully punctured with Gaia 2nd through the Sasuke (Figure 6). The Gaia 2nd went all the way back to proximal cap and was found to be subintimal by IVUS (Movie 3). The Sasuke was exchanged to Turnpike LP and retrograde wire was changed to Conquest pro 8/20. IVUS-guided retrograde puncture was performed (Movie 4). The retrograde guidewire entered the antegrade guide through 7F guide extension catheter (Movie 5). Turnpike LP was then advanced into antegrade guide. Conquest pro 8/20 was exchanged to RG3 for externalization. Sasuke microcatheter was inserted via the RG3 from the antegrade direction to facilitate distal LAD wiring with run-through NS (Movie 6). Proximal LAD CTO was dilated with 2.0/15 balloon (Figure 7). IVUS showed distal LAD negative remodeling and wire true lumen position. The LAD CTO was stented with 2.5/30 DES (Figure 8) and then post dilated with 3.0 NC balloon (Movie 7).

This case illustrates that the importance of dual lumen microcatheter in CTO intervention.