A Novel Antegrade Fenestration Subintimal Tracking Technique for CTO Intervention
Dr. Raymond Chi-Yan FUNG, Dr. Victor LEE
Princess Margaret Hospital, Hong Kong
A 70 years old male presented with exertional chest pain. He had history of inferior STEMI and had PCI to proximal RCA/LAD and LCx performed on 12/2012. His coronary angiogram showed distal LCx chronic total occlusion with ipsilateral collateral from diagonal 2 (Movie 1) and contralateral collateral from PL branch (Movie 2). The coronary stents were all patent. The CTO lesion had an ambiguous stump with an OM branch next to the proximal cap. Distal LCx CTO was wired from antegrade direction with NSrunthrough / Fielder XTA / Gaia second and Conquest Pro 12 but unsuccessful due to impenetrable proximal cap (Movie 3). D2 was then wired with Sion black supported by Corsair Pro. Distal cap was punctured with Gaia 2nd from retrograde direction. Gaia 2nd guidewire successfully crossed the CTO body but went into subintimal space. Attempt to use single guidewire redirection with Gaia 2nd /Conquest Pro from retrograde direction but failed (Movie 4). Modified reverse CART was attempted with 2.0/12, 2.5/12 and 3.0/12 NC balloons which were also unsuccessful. Retrograde knuckle wire technique was performed with Fielder XTA. The expanded subintimal space was wired successfully by Sion black from antergrade direction through the fenestration created by the 3.0/12 balloon NC balloon. The antegrade wire crossed with CTO body and went into OM4 (Movie 5). Antegrade guidewire position was confirmed by IVUS. OM3 was wired with Fielder XTA (Movie 6). OM3 to proximal LCx lesions were stented with 3 x DES after balloon dilatation. The final angiogram showed satisfactory result (Movie 7).