Chronic Total Occlusion of the Right Coronary Artery (RCA) with Anomalous Origin

Bernat Serra
Dr. Bernat Serra

Hospital Vall d’Hebron

Introduction

Chronic total occlusions (CTO) of the right coronary artery (RCA) can present additional challenges when an anomalous origin and a bifurcation at the distal cap are present. This case describes the successful recanalization of an RCA CTO following a previously failed attempt.

Patient Profile

64-year-old man

Risk Factors

  • Hypertension (HTN)
  • Dyslipidemia (DLP)
  • Obesity (BMI: 32)

Cardiovascular History

  • Angina NYHA III + Dyspnea NYHA III
  • Echocardiography: LVEF 48%, anterior hypokinesia

Lesion Type

  • RCA with anomalous origin (anterior and high implantation)
  • CTO in the RCA with:
    • Proximal cap in the mid-segment with bifurcation into a marginal branch
    • Distal cap at the PDA-PL bifurcation
  • LAD with moderate stenosis (FFR: 0.89)
  • Previous failed PCI attempt by an operator without CTO experience
  • J-CTO score: 2 (length + reattempt)

Procedure

First Attempt (Anterograde, Unsuccessful)

AWE with Finecross microcatheter:

  • Wires used: BMW, Fielder XTR, Sion, Pilot 50
  • No success

Second Attempt (Combined Anterograde and Retrograde Strategy)

Initial anterograde approach:

  • Guide extension with GuideLiner + Navitian microcatheter
  • AWE with Sion/Fielder XTR, entering a subintimal plane
  • Gladius achieved re-entry into true lumen but lacked support, displacing the system

Conversion to Retrograde Approach

  • Retrograde injection and surfing technique to identify the path
  • Wire connection attempted, but Corsair did not cross
  • Used Caravel + Guidezilla instead

Procedure Completion

  • Reverse-CART with Gladius, but microcatheter did not advance
  • Rendezvous technique: Retrograde wire connected to anterograde guiding catheter, successfully crossing with Sion
  • Predilatation with 1.5 mm and 2.5 mm balloons
  • Stent implantation:
    • Angiolite 3.0x39 mm
    • Angiolite 3.5x34 mm
    • Angiolite 3.5x34 mm
  • Postdilatation with NC balloon 4.0 mm
  • Good final angiographic result

1-Month Clinical Follow-up

  • Symptom improvement (dyspnea and angina NYHA I)
  • No clinical events

Conclusion

The combination of Reverse-CART and Rendezvous techniques enabled the successful recanalization of a complex RCA CTO with an anomalous origin, achieving a good final result and significant clinical improvement.

Figures
Figure 1. Diagnostic angiography of the RCA
Figure 1. Diagnostic angiography of the RCA
Figure 2. Failed anterograde attempt
Figure 2. Failed anterograde attempt
Figure 3. Anterograde approach with Guideliner and Navitian
Figure 3. Anterograde approach with Guideliner and Navitian
Figure 4. Attempted retrograde crossing
Figure 4. Attempted retrograde crossing
Figure 5. Reverse-Cart with Gladius
Figure 5. Reverse-Cart with Gladius
Figure 6. Guidewire connection (Rendezvous)
Figure 6. Guidewire connection (Rendezvous)
Figure 7. Predilatation with 2.5 mm balloon
Figure 7. Predilatation with 2.5 mm balloon
Figure 8. Stent implantation Angiolite 3.5x34 mm
Figure 8. Stent implantation Angiolite 3.5x34 mm
Figure 9. Postdilatation with 4.0 mm balloon
Figure 9. Postdilatation with 4.0 mm balloon
Additional material
Video 1. Final angiography (I)
Video 2. Final angiography (II)
Video 3. Final angiography (III)
Publication date