Revascularization of a CTO in the Right Coronary Artery (RCA)

Bernat Serra
Dr. Bernat Serra

Hospital Vall d’Hebron

Introduction

Chronic total occlusions (CTO) in previously revascularized arteries represent a significant challenge in coronary intervention. The presence of prior stents, complex anatomy, and the need for advanced strategies can make the procedure more difficult.

Patient Profile

  • Male, 69 years old.
  • Risk Factors: Hypertension (HTN), dyslipidaemia (DLP), latent autoimmune diabetes in adults (LADA), former smoker, overweight (BMI 27).
  • Cardiovascular History:
    • Ischemic heart disease debut in 2018 with NSTEMI Killip-Kimball I, complicated by ventricular fibrillation (VF) and recovered cardiac arrest.
    • Two-vessel coronary artery disease revascularized in LCx and RCA.
    • Previous stents: Orsiro 2.5x13 mm, Coroflex 3.0x19 mm, Ultimaster 2.25x9 mm (with distal dissection in PL), and Orsiro 2.75x13 mm.

Current Presentation

  • Unstable angina in July 2024.
  • Negative troponins.
  • Transthoracic echocardiography (TTE): Preserved LVEF. Severe hypokinesia in the inferior wall. No valvulo pathies.
  • Blood analysis: Hb: 11 g/dL | Hct: 32.6% | GFR: >90 ml/min/1.73 m².
  • SPECT: Moderate reversible ischemia in the inferolateral wall and apex. Preserved ventricular function.

Lesion Type

  • CTO in the right coronary artery (RCA).
  • J-CTO Score: 2 (difficult): Occlusion ≥20 mm and a previous failed attempt, with a blunt entry, no calcification, and no angulation greater than 45°.
  • Collateral circulation: Septal collaterals from LAD, epicardial collaterals from LCx and diagonal.

Procedure

  • The procedure was performed with femoral and bi-radial 7 Fr access using AL 0.75 and EBU 3.5 guiding catheters. To characterize the occlusion, contrast injection was performed through the Navitian microcatheter.
  • Initially, an anterograde approach (AWE) was attempted with progressive guide escalation, starting with Sion, followed by Fielder XTR, Gaia II, Gladius, Gaia III, Ultimate Bross 3, and Confianza. However, the attempt failed.
  • Given this difficulty, a retrograde attempt was made, starting with a septal test showing that S2 had no connection to the RCA, while S3 had a possible connection. Septal surfing was performed with Sion, Sion Black, and SUOH wires, complemented by a retrograde injection with the Navitian microcatheter to characterize the lesion. Finally, the occlusion was successfully crossed with the Gladius guidewire.
  • The procedure was then completed with a TIP IN technique, advancing the retrograde wire into the anterograde microcatheter, allowing conversion to an anterograde strategy. Initial pre-dilation was performed with a SC Xperience 2.0 mm balloon, followed by optimization with a Naviscore Scoring balloon 3.0 mm and NC Xperience 3.0 mm.
  • For definitive lesion treatment, stents were implanted in the following locations:
    • PL: Angiolite 2.25x24 mm.
    • From the crux to the ostium: Angiolite 3.0x44 mm + 3.5x39 mm + 3.5x19 mm.
  • A Guideliner was used for additional support, followed by post-dilation with an NC Xperience 3.5 mm balloon. Final angiographic control showed a good final result without complications.

Conclusion

In this case of CTO in the right coronary artery with multiple collaterals, the initial anterograde strategy failed due to the complexity of the occlusion. Conversion to a retrograde approach through septals enabled the successful crossing of the lesion. Finally, the TIP IN technique facilitated the completion of the procedure in an anterograde manner, achieving effective revascularization with angioplasty and stents.

Figures
Figure 1. Diagnostic angiography (I)
Figure 1. Diagnostic angiography (I)
Figure 2. Diagnostic angiography (II)
Figure 2. Diagnostic angiography (II)
Figure 3. Diagnostic angiography (III)
Figure 3. Diagnostic angiography (III)
Figure 4. Bi-radial access 7 French
Figure 4. Bi-radial access 7 French
Figure 5. Failed anterograde attempt
Figure 5. Failed anterograde attempt
Figure 6. Septal test without connection in the RCA
Figure 6. Septal test without connection in the RCA
Figure 7. TIP IN of the retrograde guidewire to the anterograde microcatheter
Figure 7. TIP IN of the retrograde guidewire to the anterograde microcatheter
Figure 8. Predilatation with SC Xperience 2.0 mm balloon
Figure 8. Predilatation with SC Xperience 2.0 mm balloon
Figure 9. Dilatation with cutting balloon Naviscore 3.0 mm and NC Xperience 3.0 mm
Figure 9. Dilatation with cutting balloon Naviscore 3.0 mm and NC Xperience 3.0 mm
Figure 10. Overlapping stents from the crux to the ostium (Angiolite 3.0x44; 3.5x39; 3.5x19 mm)
Figure 10. Overlapping stents from the crux to the ostium (Angiolite 3.0x44; 3.5x39; 3.5x19 mm)
Figure 11. Postdilatation with NC 3.5 mm balloon
Figure 11. Postdilatation with NC 3.5 mm balloon
Additional material
Video 1. Final angiography of the RCA
Publication date