Chronic Total Occlusion of the Right Coronary Artery (RCA) with IVUS-Guided Plaque Modification

Author
CiCTO Clinical Case

iVascular

Introduction

Chronic total occlusions (CTO) represent a challenge in percutaneous coronary intervention (PCI). This case describes the recanalization of an RCA CTO using an anterograde approach with intravascular imaging (IVUS) guidance and plaque modification with a cutting balloon.

Patient Profile

55-year-old man with chronic coronary syndrome (CCS II).

Risk Factors

  • Hypertension (HTN)
  • Dyslipidaemia (DLP)
  • Type 2 diabetes mellitus
  • Former smoker

Current Treatment

  • Aspirin (AAS) 100 mg
  • Bisoprolol 2.5 mg
  • Insulin
  • Ramipril 10 mg
  • Amlodipine 5 mg
  • Rosuvastatin/ezetimibe 20/10 mg
  • Empagliflozin/metformin 12.5/1000 mg

Cardiovascular History

  • Non-ST-elevation acute coronary syndrome (NSTE-ACS, 2022) with three-vessel coronary artery disease
  • Coronary artery bypass grafting (CABG)
    • LIMA → Left anterior descending artery (LAD)
    • Saphenous vein graft (SVG) → First diagonal branch
    • Radial artery → Obtuse marginal branch (OM1)
  • SPECT: Inferobasal ischemia with slight inferolateral extension, improving at rest
  • Echocardiography: LVEF 55%

Lesion Type

  • CTO in RCA with:
    • Blunt proximal cap
    • Significant calcification
    • Length ≥20 mm
  • J-CTO score: 3 (very difficult)

Procedure

Initial Anterograde Approach

  • Arterial access: Right radial 7F and right femoral 7F
  • Guiding catheter: EBU4 → LMAL1 → RCA
  • Microcatheter: Navitian + Gaia I wire
  • Successful lesion crossing with Gaia I wire

Lesion Preparation and Plaque Modification

  • IVUS for initial evaluation of the CTO
  • Cutting balloon Naviscore (2.5x12 mm and 3.0x10 mm) for lesion preparation
  • Multiple dilatations with cutting balloon, achieving adequate plaque modification

Stent Implantation and Optimization

  • Drug-eluting stents implanted:
    • Angiolite 2.5x39 mm
    • Angiolite 2.5x14 mm
    • Angiolite 3.5x39 mm
  • Good final angiographic result achieved

Conclusion

The use of IVUS and a cutting balloon enabled adequate plaque modification, facilitating the successful implantation of drug-eluting stents in an RCA CTO.

Figures
Figure 1. Diagnostic angiography of the RCA
Figure 1. Diagnostic angiography of the RCA
Figure 2. Anterograde approach with Gaia I and Navitian
Figure 2. Anterograde approach with Gaia I and Navitian
Figure 3. Lesion preparation and plaque modification with Naviscore (2.5x12 mm / 3.0x10 mm)
Figure 3. Lesion preparation and plaque modification with Naviscore (2.5x12 mm / 3.0x10 mm)
Figure 4. Stent implantation Angiolite (2.5x39 mm / 2.5x14 mm / 3.5x39 mm)
Figure 4. Stent implantation Angiolite (2.5x39 mm / 2.5x14 mm / 3.5x39 mm)
Additional material
Video 1. Final angiography
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