Revascularization of a CTO in the Right Coronary Artery with a History of TAVI

Bernat Serra
Dr. Bernat Serra

Hospital Vall d’Hebron

Introduction

Chronic total coronary occlusions (CTO) represent one of the greatest challenges in coronary intervention. The correct selection of guidewires and microcatheters is essential to successfully crossing the lesion, especially in cases with severe calcification and complex anatomy. Collaterals: Septal from LAD.

Patient Profile

  • 77-year-old male.
  • Medical history: Hypertension (HTN), dyslipidaemia (DLP), chronic obstructive pulmonary disease (COPD) GOLD III.
  • Cardiovascular disease: Paroxysmal atrial fibrillation, ischemic heart disease with exertional angina, and three-vessel coronary artery disease (mid LAD + OM1 + CTO in the right coronary artery [RCA]).
  • Previous complete revascularization in 2021.
  • TAVI implantation in 2022 with an Edwards Sapien 3 Ultra 23 mm prosthesis via the right femoral approach.

Clinical Presentation

  • Post-TAVI evolution with improvement in dyspnea. Progressive exertional angina up to NYHA III, despite optimal medical treatment. One hospital admission due to heart failure. Imaging test (SPECT) showing severe ischemia in the inferior and lateral walls.
  • Indication for a new PCI on the RCA CTO due to in-stent restenosis (ISR) at the stent edge.

Lesion Type

  • CTO in the right coronary artery (RCA).
  • Previous crossing attempt at the same lesion, length ≥20 mm, and no significant calcification.
  • J-CTO Score: 2 (difficult).

Procedure

  • Biradial 7 French access with JRA and EBU 3.5 guiding catheters.
  • Use of a 7 French catheter extender (Guidezilla) to improve stability.
  • Initial attempt with Sion guidewire, followed by Fielder XTR and Gladius.
  • The Gladius guidewire successfully crossed the occlusion with confirmation in the true lumen.
  • Pre-dilation with Xperience balloons 2.25x20 mm and 3.5x30 mm.
  • Implantation of Angiolite stents 3.0x39 mm and 3.0x44 mm.
  • Post-dilation with a non-compliant (NC) Xperience 3.5 mm balloon.
  • A good angiographic result was obtained with adequate stent expansion and apposition.

Conclusion

The Navitian microcatheter facilitated the crossing of the calcified CTO in the LAD, enabling a successful procedure through the anterograde approach. The appropriate selection of guidewires and balloons allowed for the optimization of the final result, without complications.

Figures
Figure 1. Previous angioplasty
Figure 1. Previous angioplasty
Figure 2. Previous TAVI implantation
Figure 2. Previous TAVI implantation
Figure 3. Diagnostic angiography
Figure 3. Diagnostic angiography
Figure 4. Bi-radial access 7 French
Figure 4. Bi-radial access 7 French
Figure 5. Support optimization with positioning of Guidezilla 7F catheter extender
Figure 5. Support optimization with positioning of Guidezilla 7F catheter extender
Figure 6. Advancement of Gladius guidewire through the CTO
Figure 6. Advancement of Gladius guidewire through the CTO
Figure 7. Predilatation of the RCA with Xperience
Figure 7. Predilatation of the RCA with Xperience
Figure 8. Stent implantation Angiolite
Figure 8. Stent implantation Angiolite
Figure 9. Postdilatation with NC Xperience 3.5 mm balloon
Figure 9. Postdilatation with NC Xperience 3.5 mm balloon
Additional material
Video 1. Final angiography of the RCA
Publication date