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

Author
CiCTO Clinical Case

iVascular

Introduction

Chronic total occlusions (CTO) continue to pose a challenge in percutaneous coronary intervention (PCI), especially in patients with severe ischemia. This case describes the recanalization of a CTO in the right coronary artery (RCA) using an anterograde approach, highlighting the performance of the Navitian microcatheter.

Patient Profile

Age and Gender: 69-year-old woman

Medical History

  • Hypertension (HTN)
  • Dyslipidaemia (DLP)
  • Diabetes mellitus (DM)

Cardiovascular History

No previous history

Clinical Presentation

  • Exertional angina (NYHA III)
  • Severe inferior ischemia on SPECT
  • Echocardiography: LVEF of 48% with inferior hypokinesia

Pharmacological Treatment Before Intervention

  • Aspirin (AAS) 100 mg/day
  • Nitrates
  • Bisoprolol 5 mg/day
  • Ranolazine 500 mg/12 h
  • Rosuvastatin 40 mg/day
  • Enalapril 10 mg/day
  • Metformin 850 mg/12 h

Lesion Type

Coronary Disease

Single CTO in the RCA

Anatomical Characteristics

  • Proximal cap: Blunt, ambiguous
  • Distal cap: Before the PL-PDA bifurcation
  • Collaterals: From the circumflex artery (LCx) and septal branches of the LAD
  • J-CTO score: 2
    • Blunt cap
    • Extensive length
    • Epicardial collaterals from LCx
    • Septal collaterals from LAD
    • Right marginal ventricular branches (RVMB)

Procedure

Vascular Access

  • Biradial approach with 7F introducer
  • Guiding catheters: EBU 3.5 and AR II
  • Protection wire: Sion Blue

Anterograde Strategy (AWE)

Microcatheter used: Navitian

Wires Used

  • Sion: Failure
  • Fielder XTR: Failure
  • GAIA II: Failure
  • Gladius: Success in recanalization

True Lumen Confirmation

Navitian crossed the lesion without difficulty

Dilatation and Stent Placement

  • Predilatation with semi-compliant (SC) Xperience balloons:
    • 1.5 mm and 2.25 mm
  • Stent implantation (Angiolite):
    • 3.5x29 mm
    • 3.0x24 mm
    • 4.0x8 mm
    • 3.0x29 mm
  • Postdilatation with non-compliant (NC) balloon: 3.5-4 mm

Conclusion

The Navitian microcatheter enabled efficient recanalization in a complex CTO case with a blunt proximal cap and interventricular collaterals. The intervention was successfully completed using the anterograde strategy, achieving effective restoration of coronary flow.

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
Figure 4. Confirmation of true lumen
Figure 5. Predilatation with balloon before implantation
Figure 5. Predilatation with balloon before implantation
Figure 6. Intravascular ultrasound
Figure 6. Intravascular ultrasound
Figure 7. Stent implantation Angiolite 3.5x29/3.0x24 mm
Figure 7. Stent implantation Angiolite 3.5x29/3.0x24 mm
Figure 8. Stent implantation Angiolite 4.0x8 mm
Figure 8. Stent implantation Angiolite 4.0x8 mm
Figure 9. Stent implantation Angiolite 3.0x29 mm
Figure 9. Stent implantation Angiolite 3.0x29 mm
Figure 10. Postdilatation with non-compliant balloon
Figure 10. Postdilatation with non-compliant balloon
Additional material
Video 1. RCA occlusion
Video 2. Post-procedure angiography
Publication date