Chronic Total Occlusion of the Right Coronary Artery (RCA) (I)

Author
CiCTO Clinical Case

iVascular

Introduction

Chronic total occlusions (CTO) represent a significant challenge in percutaneous coronary intervention (PCI). Selecting the appropriate strategy and using innovative devices can optimize procedural success and reduce complications. This case presents the recanalization of a CTO in the right coronary artery (RCA), highlighting the performance of the Navitian microcatheter in the anterograde strategy.

Patient Profile

Age and Gender: 64-year-old woman

Medical History

  • Smoker
  • Hypertension (HTN)
  • Dyslipidaemia (DLP)
  • Obesity
  • Hodgkin's lymphoma in remission (>20 years)

Clinical Presentation

  • Progressive exertional angina (NYHA III)
  • Progressive dyspnoea
  • Left ventricular ejection fraction (LVEF) 55%
  • Non-transmural necrosis of the inferior myocardium with demonstrated viability
  • Porcelain aorta
  • Preserved renal function (eGFR >90 ml/min)

Lesion Type

  • Left anterior descending artery (LAD): No significant stenosis
  • Circumflex artery (LCx): No significant stenosis
  • Right coronary artery (RCA): CTO in the proximal segment with:
    • Proximal cap: Blunt cap after the auricular branch
    • Extensive occlusion length (measurement not specified in the image)
    • J-CTO score: 3 (Blunt cap, length, previous failed attempt)
    • Presence of septal collaterals from LAD, diagonal, and apical LAD

Procedure

1. Vascular Access

  • Bilateral radial approach with 7F introducer
  • Guiding catheters: EBU 3.5 and AL 0.75
  • Use of Sion Blue safety wire

2. Initial Strategy - Anterograde Approach

  • Navitian microcatheter used with anterograde access
  • Wires Used:
    • Sion: Failed
    • Fielder XTR: Failed
    • GAIA II: Successful recanalization

3. Confirmation of true lumen and initial dilation

  • Confirmation with ICUS (intra-coronary ultrasound)
  • Difficulty crossing the microcatheter, requiring pre-dilation with a 1.5 mm balloon

4. Procedure Completion

  • Two additional pre-dilation procedures performed:
    • Semi-compliant Xperience balloon 2.5 mm
    • Scoring balloon Naviscore 3.0 mm
  • Implantation of two Angiolite stents (3.0x39mm and 3.5x39mm) with a satisfactory angiographic result
  • Post-dilation with a 4.0 mm non-compliant Xperience balloon

Conclusion

The Navitian microcatheter demonstrated excellent navigational capability in the anterograde approach of a CTO with an unfavourable proximal cap and extensive length. Despite the initial difficulty in crossing the lesion, the use of complementary strategies such as pre-dilation allowed for the successful completion of the procedure. This case highlights the importance of specialized tools in the recanalization of complex CTOs.

Figures
Figure 1. Diagnostic angiography of the RCA
Figure 1. Diagnostic angiography of the RCA
Figure 2. Radial approach with guide catheters
Figure 2. Radial approach with guide catheters
Figure 3. Attempt to cross with Navitian
Figure 3. Attempt to cross with Navitian
Figure 4. Confirmation of true lumen with IVUS/USIC
Figure 4. Confirmation of true lumen with IVUS/USIC
Figure 5. Predilatation with balloon before implantation (2.5 Xperience)
Figure 5. Predilatation with balloon before implantation (2.5 Xperience)
Figure 6. Predilatation with balloon before implantation (3.0 Naviscore)
Figure 6. Predilatation with balloon before implantation (3.0 Naviscore)
Figure 7. Stent implantation (I) (Angiolite)
Figure 7. Stent implantation (I) (Angiolite)
Figure 8. Stent implantation (II) (Angiolite)
Figure 8. Stent implantation (II) (Angiolite)
Additional material
Video 1. Right coronary artery, diagnostic angiography (I)
Video 2. Right coronary artery, diagnostic angiography (II)
Video 3. Right coronary artery, diagnostic angiography (III)
Video 4. Post-procedure angiography
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