Chronic Total Occlusion of the Left Anterior Descending Artery (LAD) in a Patient with Previous Revascularization Surgery

CiCTO Clinical Case

iVascular

Introduction

Chronic total occlusions (CTO) in patients with previous revascularization surgery represent a significant challenge in percutaneous coronary intervention (PCI). This case describes the recanalization of a CTO in the LAD, using an anterograde approach and the support of the Navitian microcatheter for lesion preparation.

Patient Profile

Age and Gender: 79-year-old woman

Medical History

Dyslipidemia
Hypertension (HTN)
Former smoker

Cardiovascular History

2017: Ascending aortic dissection with surgical repair
2017: Coronary artery bypass grafting (CABG)
- Saphenous vein graft (SVG) to the LAD
May 2024: ST-elevation myocardial infarction (STEMI)
- CTO in LAD and severe stenosis in SVG (TIMI Flow 1)
- PCI in SVG with graft perforation
- 2 mm stent implantation with final TIMI Flow 3

Ventricular Function

Left ventricular ejection fraction (LVEF): 35%

Pharmacological Treatment Before Intervention

Aspirin (AAS) 100 mg
Clopidogrel 75 mg
Furosemide 40 mg
Spironolactone 25 mg
Bisoprolol 2.5 mg
Famotidine 40 mg
Dapagliflozin 10 mg
Ramipril 2.5 mg

Lesion Type

Affected Artery

LAD

Anatomical Characteristics

Chronic occlusion with calcification present
Occlusion length ≥ 20 mm
Previous failed recanalization attempt

J-CTO Score

Difficulty category: Difficult (2 points)
Entry cap morphology: Non-tapered cap (0 points)
Angulation: ≥ 45° (0 points)

Procedure

Vascular Access and Preparation

Left and right femoral arterial access with 7F introducers
Guiding catheters:
- EBU 4 7F
- XB ACR 6F
Procedure guided by IVUS

Initial Strategy

Initial approach: Attempt to cannulate SVG
Initial wire: Sion Blue

Anterograde Approach (AWE)

Wires used in escalation strategy:
- Fielder XT-A
- Gaia I
- Gaia II
- Gaia III
- Gladius MG (successfully crossed the distal cap)

Microcatheter Used

Navitian (iVascular)

Lesion Preparation and PCI

Wire exchange with Sion Blue ES
Predilatation
Stent implantation:
- Angiolite 2.5x39 mm (iVascular)
Postdilatation with non-compliant (NC) balloon: 2.5/3.0 mm

Conclusion

The use of the Navitian microcatheter facilitated the anterograde recanalization of a CTO in the LAD in a patient with previous revascularization surgery. The guidewire escalation strategy allowed for successful occlusion crossing, achieving an optimal final result after implantation of the Angiolite stent.

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