Complex RCA CTO: from antegrade to retrograde approach achieved with Navitian

Doctor Roberto Garbo
Prof. Roberto Garbo

Maria Pia Hospital, GVM Care & Research, Turin, Italy. Director of CTO and Complex PCI Program.

Patient profile

  • Patient 64 years old and male.
  • Risk factors: Smoker, hypertension and dislipidemia.
  • In 1997 he presented an Acute Coronary Syndrome and a PCI with BMS on the RCA was implanted.
  • In December 2020 he presented an anterior NSTEMI.

Lesion type

  • RCA CTO post stent was detected (Figure 1). In February he presented and angina for minimal effort so an RCA CTO PCI was scheduled the 26th of March 2021.
  • Mid LAD subocclusion was solved with DES implantation was performed, with good result.

Procedure

  • We started with antegrade approach with IVUS guidance for entry point (Figure 2) and Navitian 135 cm for antegrade puncture with Gaia 3rd (Figure 3). We did a step down with Fielder (Figure 4). Antegrade approach failed due to calcification at proximal cap detected by IVUS.
  • Retrograde approach was needed, with Navitian 150 cm and Sion black (Figure 5). In order to cross through a stent, a pre-dilatation was needed with small balloon of 1.5mm (Figure 6). After this, Navitian could advance and crossing septal collaterals (Figure 7) over a stented LAD.
  • After retrograde Knuckle with Gladius EX wire in the subintimal space, the connection between the two wires was obtained with Reverse CART technique (Figure 8) , with Gaia 2nd re-entry in the guiding catheter (Figure 9), externalization and subsequent PCI and stenting (Figure 10). The final result was very good (Figure 11).
  • At 1 month follow up he is free of angina in very good clinical condition.

Conclusion

“The performance of Navitian was really good both in antegrade and retrograde, the overall performance of the device in terms of profile, crossability and support was at high quality level. In retrograde approach, after balloon dilatation over stent struts, the Navitian 150 easily crossed the septal giving us good feedback for the rest of the procedure.”

Prof. Roberto Garbo   
Maria Pia Hospital, Turin, Italy

Figures
Figure 1. RCA CTO post stent
Figure 1. RCA CTO post stent
Figure 2. IVUS entry point
Figure 2. IVUS entry point
Figure 3. Navitian 135 with gaia 3rd advance
Figure 3. Navitian 135 with gaia 3rd advance
Figure 4. Step down with Fielder
Figure 4. Step down with Fielder
Figure 5. Navitian 150 and Sion black advance
Figure 5. Navitian 150 and Sion black advance
Figure 6. Balloon dilatation 1.5mm
Figure 6. Balloon dilatation 1.5mm
Figure 7. Navitian 150 crossing septal
Figure 7. Navitian 150 crossing septal
Figure 8. Reverse CART
Figure 8. Reverse CART
Figure 9. Reentry gaia 2nd
Figure 9. Reentry gaia 2nd
Figure 10. Externalization
Figure 10. Externalization
Figure 11. Final result RCA
Figure 11. Final result RCA
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