Stuck Turnpike in RCA CTO
Dr. Wei-Lun MAK, Dr. Yu-Ho CHAN
Pok Oi Hospital, Hong Kong
A 50-year-old gentleman presented with increasing effort angina despite optimal medical treatment. He enjoyed good past health and was a non-smoker. Baseline echocardiogram showed mild impaired LV ejection fraction of 45-50% and with mild hypokinesia over LAD and RCA territory. Coronary angiogram showed triple vessel disease with short CTO of mLCx and mRCA. There was 70% stenosis over mLAD (Figure 1, Figure 2, Movie 1, Movie 2). PCI to RCA CTO was attempted using antegrade approach.
After engaging the RCA with a JR4 guiding, the lesion was able to cross with XT-A guidewire supported by finecross microcatheter (Movie 3). An attempt to cross the CTO lesion with finecross was failed. A short 1.0 balloon was failed to cross despite using anchoring technique (Figure 3). An attempt to cross the CTO with a turnpike microcatheter was also failed and it was found that the tip of the microcatheter got stuck at the proximal cap. Further rotation resulted in separation of the tip from its shaft of the microcatheter (Movie 4). Parallel wire technique was tried to bypass the lesion but it went into subintimal space (Figure 4). Fortunately, there was no compromised of antegrade flow (Movie 5) and the patient remained stable. It was decided to leave the broken head of turnpike insitu and planned for a stage procedure using retrograde approach. LAD stenosis was first fixed and bilateral injection show good distal septal collateral to PDA (Movie 6). Septal channel was cross with a Sion guidewire supported by turnpike LP microcatheter (Movie 7). The distal cap was tried to puncture by Gaia 2nd but it failed (Movie 8). Antegrade wiring was attempted again for reverse CART. Antegrade knuckle wiring technique (XT-A guidewire) was used to bypass the calcified CTO lesion with the stuck microcatheter tip (Figure 5). Intentional subintimal wiring technique was used to put the 2 guidewires close together (Figure 6). Reverse CART was successfully performed using a 2.5 balloon and retrograde Gaia 2nd guidewire (Figure 7). Externalization was achieved and the case was successfully completed after putting 2 overlapping DES (Movie 9, Movie 10). PCI to LCx CTO was planned at a later stage.
