Chronic Total Occlusion of the Right Coronary Artery (RCA) and the Circumflex Artery (LCx)

Author
CiCTO Clinical Case

iVascular

Introduction

Chronic total occlusions (CTO) of the right coronary artery (RCA) and the circumflex artery (LCx) can pose a technical challenge in percutaneous coronary intervention (PCI). This case describes the successful recanalization of both CTOs through anterograde and retrograde approaches guided by IVUS.

Patient Profile

  • Male, 69 years old, with multiple comorbidities.
  • Risk factors: Hypertension (HTN), dyslipidaemia (DLP), type 2 diabetes mellitus, obesity, and atrial fibrillation.
  • Cardiovascular history:
    • Acute myocardial infarction in 2001 with stent implantation in the LAD.
    • Peripheral vasculopathy - Right femoropopliteal bypass.
    • Chronic coronary syndrome (CCS II).
    • LVEF 34%, without segmentation abnormalities.
  • Medication on admission:
    • Aspirin 100 mg, bisoprolol 2.5 mg, acenocoumarol 4 mg, ezetimibe 10 mg, atorvastatin 80 mg, omeprazole 20 mg, semaglutide 1 mg, dapagliflozin 10 mg, insulin 100 IU/mL, metformin 1000 mg, amlodipine/valsartan/HCT 10/320/25 mg, isosorbide mononitrate 40 mg.
  • Additional tests:
    • SPECT: Inferoseptal-apical ischemia with moderately depressed systolic function.
    • CMR: Chronic subendocardial infarctions in the proximal RCA and mid LCx territories, both with residual viability.

Lesion Type

  • CTO of the RCA (J-CTO Score: 1, intermediate).
    • Length ≥ 20 mm (1 point).
    • Favourable entry morphology, absence of calcification, and angulation <45°.
  • CTO of the LCx (J-CTO Score: 2, difficult).
    • Blunt entry and lesion length ≥ 20 mm.
    • Absence of calcification and angulation <45°.

Procedure

CTO of the RCA – Anterograde Approach

  • Arterial access: Right radial 7F and left radial 7F.
  • Guiding catheter: EBU 3.5/4.0 in the left main coronary artery (LMCA) and AL 0.75 in the RCA.
  • Navitian microcatheter (iVascular) + Fielder XT-A wire.
  • Initial attempt failed with Fielder XT-A.
  • Successful crossing with Gaia II wire.
  • Lesion preparation and stent placement:
    • Pre-dilation with NC balloons of 2.0 mm and 3.0 mm.
    • Implantation of Angiolite stents (2.5x44 mm and 3.0x34 mm) with overlap.
    • Post-dilation with NC balloon of 3.5 mm.

CTO of the LCx – Sequential Retrograde and Anterograde Approach

  • Initial retrograde attempt through apical epicardial collateral with Sion wire, unsuccessful due to tortuosity.
  • Retrograde attempt via LCx collateral with Sion and Gaia II, failed to cross, so it was left as a marker.
  • Switch to anterograde approach with Gladius MG wire and Turnpike Spiral microcatheter.
  • Successful crossing with kissing wires technique.
  • Pre-dilation with NC balloons 1.5/2.0/3.0 mm.
  • Failed attempt to cross with Naviscore balloon due to severe calcification.
  • Guiding catheter switched to EBU 4, 7F (ping-pong technique).
  • Using Telescope microcatheter, crossing and pre-dilation were achieved with Naviscore and NC balloons.
  • Implantation of Angiolite stents (3.0x29 mm and 3.0x24 mm).
  • Finalization with POT, rewiring, kissing, and Essential balloon in the LAD.
  • Good final angiographic result was obtained.

30-Day Follow-Up

Clinically asymptomatic, without dyspnea or angina, and with functional improvement.
Aspirin discontinuation was indicated.

Figures
Figure 1. Baseline coronary angiography of the RCA
Figure 1. Baseline coronary angiography of the RCA
Figure 2. Baseline coronary angiography of the circumflex artery
Figure 2. Baseline coronary angiography of the circumflex artery
Figure 3. Initial approach of the RCA
Figure 3. Initial approach of the RCA
Figure 4. Stent implantation Angiolite overlapping (2.5x44 mm / 3.0x34 mm)
Figure 4. Stent implantation Angiolite overlapping (2.5x44 mm / 3.0x34 mm)
Figure 5. Postdilatation with 3.5 mm balloon
Figure 5. Postdilatation with 3.5 mm balloon
Figure 6. Initial approach of the circumflex artery
Figure 6. Initial approach of the circumflex artery
Figure 7. Crossing of the occlusion with anterograde approach in the circumflex artery
Figure 7. Crossing of the occlusion with anterograde approach in the circumflex artery
Figure 8. Stent implantation Angiolite up to the LM
Figure 8. Stent implantation Angiolite up to the LM
Additional material
Video 1. Final angiography of the RCA
Video 2. Crossing of occlusion in the circumflex artery with kissing wires technique
Video 3. Final post-procedure angiography in the circumflex artery
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