Doctor & Patient Education Cardiac Specialist Centre
Intervention
3. Left Circumflex CTO
CASE HISTORY
  • This 53 year old lady presented with angina
  • The Nuclear stress test showed large area of ischaemia in the lateral and inferior wall
  • Coronary CT scan showed significant LCx vessel disease
  • The 1st attempt in another hospital was via right radial route
  • Only antegrade wiring with up to 2 wires were attempted
  • This attempt was not successful

The 1st angiogram
5F Tiger diagnostic


 

The wire is in the sub-intimal space
6.5F Sheathless Eaucath PB 3.0 with Miracle 6 wire over
Finecross microcatheter


 

LAO view shows wire is not in vessel
Final attempt with Gaia 2nd wire
Procedure was abandoned


Discussed with patient
  • After studying the angiogram for the 1st failed attempt
  • I felt that a retrograde approach should result in success as there is adequate collateral filling
  • There is another lesion in the proximal LAD which will also need to be treated
  • The 2nd attempt should be via the groin approach as a 7F catheter is needed

The 2nd attempt
7F AL2 guide
Angio shows the collateral channels


 

Wiring the septal channel
Sion on Corsair entering septal


 

Bidirectional wiring
Sion in LCx stump
Fielder XT-R in retrograde crossing


 

RAO caudal and Left Lateral views
Gaia 2nd crossed into LCx and 2 orthogonal views are used to verify that the retrograde wire has entered true lumen



 

The whole LCx and OM2 branch are now visible
RG3 externalised and LCx dilated with Ikazuchi 2.5 x 15mm balloon


 

OM2 is wired and treated with Drug-Eluting Balloon
Run through in LCx, Fielder FC in OM2
OM2 is treated with Sequence Please 2.5 x 20mm DEB


 

Using Intra-Vascular Ultrasound (IVUS) to identify the ostium for OM1
OM1 ostium entered with Fielder FC. CTO segment crossed with XT-A over Corsair


 

After dilatation of OM1
OM1 dilated with Ikazuchi balloon 2.5 x 15


 

Stent placed across OM1 and OM2 in the Left Circumflex artery
Xience 3.0 x 38 placed in LCx jailing both OM1 and OM2 wires


 

Completing the treatment of LCx

  • OM1 2.5 x 15 and
  • LCx 3.0 x 15 kissing balloon performed
  • The OM1 was then stented with Absorb 2.5 x 12 Bio-absorbable stent
  • The pLAD was also stented with Absorb 3.0 x 18 BVS
 

 

The final angiogram
RAO caudal view showing complete revascularization of the Left Circumflex artery


 

Final angiogram
The whole LCx is now completely visualised


 

Comparison of Before and After
The occlusion before stenting


 

CONCLUSION
  • This case illustrates how a chronic total occlusion (CTO) of a vessel can be treated using ‘Retrograde’ wiring approach
  • This technique is time consuming and requires high level of skill and patience
  • However, if successful, it can open up completely blocked arteries
  • In this case, not only is the main artery is opened, the branches are also successfully opened
  • The standard antegrade approach was used for treating the OM1 branch
Consultation
Know Your Cardiologists

I feel breathless when walking.

I feel a tightness over my chest.

Do I need to take my medicine for my blood pressure?

Do I need to take my medicine for my cholesterol?

Do I really need stents for my artery?

Do I really need to have a bypass operation?

When should I go for health screening?

I have heart problem, can I take Viagra?

I have heart problem, should I exercise?

Heart Disease
Learn about your heart Conditions

You may need an ultra sound scan of your heart to assess its function.

You may need a treadmill stress test.

You may need closer monitoring.

You may need a more thorough risk assessment and life style change.

You may only need to take your medicine.

You may get away with just stenting.

This generally should start at 40 years old.

Yes, but there are certain strict conditions to fulfill.

Yes, but you will need to find out the appropriate intensity.