Chronic Total Occlusion of the Right Coronary Artery (RCA) in a Patient with Multiple Comorbidities

Bernat Serra
Dr. Bernat Serra

Hospital Vall d’Hebron

Introduction

Chronic total occlusions (CTO) represent one of the greatest challenges in PCI, especially in patients with multiple comorbidities. In this case, a CTO of the RCA was approached using a combination of anterograde and retrograde strategies, allowing for successful vessel recanalization.

Patient Profile

67-year-old man with progressive angina NYHA III-IV.

Risk Factors

  • Active smoking
  • Hypertension (HTN)
  • Dyslipidaemia (DLP)
  • Type 2 diabetes mellitus

Relevant Medical History

  • Severe diffuse interstitial lung disease
  • Cirrhosis with portal hypertension
  • Moderate mitral insufficiency with pulmonary hypertension (PASP 70 mmHg)

Diagnostic Tests

  • LVEF 58%, no segmental abnormalities
  • CMR: Viability in the inferior territory, ischemia in LAD and RCA

Lesion Type

LAD

  • Severe stenosis with severe calcification

RCA

  • CTO in the mid-segment, with blunt proximal cap and distal cap at bifurcation
  • Severe atheromatosis in the distal RCA
  • Collaterals from S1-S2 and apical LAD

J-CTO Score

  • Score: 2 (length + blunt cap)

Procedure

PCI in LAD

  • Anterograde PCI with 7F radial access
  • Guiding catheter: XB 3.5 in LAD
  • Rotational atherectomy with 1.5 mm burr
  • Predilatation with SC balloon 2.5 mm, followed by cutting balloon 3.25 mm
  • Implantation of two drug-eluting stents (2.5x23 mm and 3.5x23 mm)
  • Postdilatation with NC balloon 4.0-4.5 mm
  • 6-month follow-up: Persistence of angina NYHA III, leading to the decision to treat RCA CTO

PCI in RCA - CTO

  • Initial anterograde approach with Navitian microcatheter and anterograde wire escalation
  • Attempted crossing with Sion, followed by Fielder XTR, Gaia II, and Gladius, without success

Retrograde Approach

  • Pilot 50 wire advanced, successfully crossing the distal occlusion
  • Connection with Sion Black in distal RCA
  • Corsair Pro advanced to the distal cap
  • Retrograde connection performed using Reverse-CART technique
  • Balloons (1.5 - 2.5 - 3.0 mm) used to facilitate re-entry
  • Retrograde Gladius wire successfully connected with the guiding catheter
  • Externalization with RG3 wire
  • Lesion preparation before stent implantation
  • True lumen position confirmed with IVUS
  • Predilatation with SC balloons 2.5 mm and 3.0 mm
  • Naviscore 3.5 mm cutting balloon used due to circumferential calcification >270°

Stent Implantation

  • Three drug-eluting stents implanted in RCA:
    • Angiolite 3.5x39 mm
    • Angiolite 3.5x39 mm
    • Angiolite 3.5x19 mm (from distal to proximal segment)
  • Postdilatation with NC balloon 4.5 mm
  • Control angiography showed good final result with restored RCA flow.

Conclusion

The use of the Navitian microcatheter facilitated the recanalization of a complex CTO in the RCA, enabling a successful hybrid strategy. The combination of anterograde and retrograde approaches, along with the Reverse-CART technique, resulted in effective revascularization and significant clinical improvement.

Figures
Figure 1. Diagnostic angiography of the ADAI
Figure 1. Diagnostic angiography of the ADAI
Figure 2. Diagnostic angiography of the RCA
Figure 2. Diagnostic angiography of the RCA
Figure 3. PCI in the ADAI, radial Access
Figure 3. PCI in the ADAI, radial Access
Figure 4. Predilatation with balloon in the ADAI
Figure 4. Predilatation with balloon in the ADAI
Figure 5. Stent implantation in the ADAI
Figure 5. Stent implantation in the ADAI
Figure 6. Postdilatation with non-compliant balloon in the ADAI
Figure 6. Postdilatation with non-compliant balloon in the ADAI
Figure 7. Anterograde approach in the RCA
Figure 7. Anterograde approach in the RCA
Figure 8. Retrograde approach in the RCA
Figure 8. Retrograde approach in the RCA
Figure 9. Predilatation with cutting balloon in the RCA
Figure 9. Predilatation with cutting balloon in the RCA
Figure 10. True lumen positioning
Figure 10. True lumen positioning
Figure 11. Stent implantation in the RCA
Figure 11. Stent implantation in the RCA
Figure 12. Postdilatation with NC balloon in the RCA
Figure 12. Postdilatation with NC balloon in the RCA
Additional material
Video 1. Final angiography (I)
Video 2. Final angiography (II)
Video 3. Final angiography (III)
Publication date