A Calcified and Tortuous RCA CTO

A 70 years old male presented with chest pain. He had PCI to LAD in 2015. His coronary angiogram showed prox RCA 80% stenosis, mid RCA CTO with antegrade bridging collaterals from prox RCA (Movie 1), distal RCA 90% stenosis with retrograde collaterals from septals and patent LAD stent (Movie 2).

RCA was engaged with 7F AL 0.75 guide. Antegrade wiring with Fielder XTA/ miracle 6 supported by corsair microcatheter failed to penetrate prox cap. LM was engaged with 7F EBU 3.5 guide. Different septal channels were attempted with Sion guidewire supported by Corsair microcatheter.  They ended up in septal perforations due to tortuosities and acute bends (Movie 3).

PCI was reattempted a few months later with 8F MAC guide to RCA, 7F EBU 3.5 guide to LM. RCA CTO was wired from antegrade direction with Gaia 3rd/ Pilot 200/ Conquest pro supported by Turnpike spiral.  Proximal cap was successfully punctured by Conquest Pro guidewire, but the guidewire was unable to follow the tortuous vessel. After dilated the prox RCA lesion with 2.5/15 balloon. An 8F Guideliner was used. The turnpike was anchored with a 2.5/15 balloon (supported by a knuckled NS run-through guidewire). The conquest pro 8/20 could be further advanced into the CTO body (BASE technique). However, the guidewire position was far away from distal vessel (Movie 4). Even with this level of support, Turnpike or small balloon could not be advanced into the prox cap. Retrograde wiring was then began. After several failed attempts of wiring septal channels, finally a tortuous septal channel could be wired with Sion black supported by Finecross microcatheter. After reaching the PDA, the Sion black was exchanged to Sion blue (Figure 1). It crossed the distal RCA lesion and reached the distal cap (Movie 5). Direct retrograde wire crossing with Gaia 2nd was unsuccessful due to uncertain vessel course.  The CTO was finally negotiated by Pilot 200 GW using knuckle wire technique (Movie 6). Further attempt to perform reentry into proximal true lumen with Gaia 3rd was unsuccessful. Reattempt antegrade guidewire crossing with Conquest Pro 8/20 end up in losing the antegrade system. RCA was then engaged with 7F JR 4 guide together with 7F guideliner.  ‘Guideliner modified reverse CART’ was performed by dilating segment proximal to the prox cap with 3.5/12 balloon (Figure 2). Subintimal dissection reentry was performed with conquest pro 8/20 from retrograde direction (Movie 7). After confirming the retrograde guidewire position with IVUS, the guidewire was then advanced into the antegrade guideliner, followed by finecross microcatheter. Externalization was done with RG3. Distal to prox RCA lesions were dilated with 3.0/15 balloon and then stented with 4 x DES followed by post-dilatation with 3.0/18 NC balloon. Good angiographic result achieved (Movie 8).