Chronic Total Occlusion of the Right Coronary Artery (RCA)

Bernat Serra
Dr. Bernat Serra

Hospital Vall d’Hebron

Introduction

A 65-year-old patient with a history of arterial hypertension (HTN), dyslipidaemia (DLP), type II diabetes mellitus (DM II), active smoking, and chronic obstructive pulmonary disease (COPD). The patient presents with angina classified as NYHA functional class II-III.

Preoperative Evaluation

  • Echocardiogram: LVEF 56%, mild inferior hypokinesia.
  • Electrocardiogram: Not described in the report.
  • Laboratory: Hemoglobin 16.6 g/dL, hematocrit 50.3%, glomerular filtration rate >90 ml/min/1.73 m², creatinine 0.42 mg/dL.
  • SPECT: Inferior/inferolateral non-transmural necrosis with moderate ischemia.
  • J-CTO classification: 0.
  • Collaterals: Septal from LAD.

Procedure

A bi-radial approach was chosen using EBU 3.5 7F and Amplatz Left 0.75 7F guiding catheters. The anterograde wire escalation (AWE) technique was employed.

  1. Crossing of the occlusion with a Navitian microcatheter and a Fielder XTR wire.
  2. Partial CTO predilation with an SC Xperience 2.5 mm balloon.
  3. Complete RCA predilation with an SC Xperience 2.5 mm balloon.
  4. Control angiography: Good predilation, but ostium dissection secondary to catheter manipulation.
  5. Angioplasty with drug-coated balloon (DCB) Essential Pro 2.5x25 mm and 3.0x25 mm (from the distal segment of the RCA to the distal cap of the CTO).
  6. Implantation of an Angiolite 3.5x49 mm stent.
  7. Postdilation with an NC Xperience 4.0 mm balloon.

Final Outcome

  • Successful revascularization of the RCA with a satisfactory final angiographic result.
  • The procedure was performed without immediate complications.

Conclusion

In this case of RCA CTO, the bi-radial approach strategy and the use of the anterograde wire escalation (AWE) technique enabled a successful lesion crossing. The combination of angioplasty with a drug-coated balloon and stent implantation resulted in effective revascularization without immediate complications. This approach demonstrates the efficacy of advanced strategies in the treatment of complex CTO cases.

Figures
Figure 1. Baseline angiography of the RCA
Figure 1. Baseline angiography of the RCA
Figure 2. Angiography of the ADAI with septal collateral circulation
Figure 2. Angiography of the ADAI with septal collateral circulation
Figure 3. Initial approach. Positioning of guide catheters with bi-radial access
Figure 3. Initial approach. Positioning of guide catheters with bi-radial access
Figure 4. Attempted crossing with Fielder XTR guidewire and Navitian microcatheter
Figure 4. Attempted crossing with Fielder XTR guidewire and Navitian microcatheter
Figure 5. Angiography after partial predilatation with SC Xperience balloon
Figure 5. Angiography after partial predilatation with SC Xperience balloon
Figure 6. Angiography after complete predilatation of the RCA
Figure 6. Angiography after complete predilatation of the RCA
Figure 7. Stent implantation Angiolite 3.5x49 mm
Figure 7. Stent implantation Angiolite 3.5x49 mm
Figure 8. Postdilatation with NC Xperience 4.0 mm balloon
Figure 8. Postdilatation with NC Xperience 4.0 mm balloon
Additional material
Video 1. Final angiography of the RCA
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