Triple crossing – microcatheter usefulness in a long-calcified LAD CTO
Introduction
Chronic Total Occlusions (CTOs) represent one of the most challenging procedures in coronary interventional cardiology. Outcomes of PCI in CTOs have improved considerably thanks to advancements in devices (namely dedicated guidewires) and technique refinement. Microcatheters are an essential tool for optimal wire manipulation. The microcatheter should provide support for wire advancement, be able itself to cross the lesion and allow wire exchange.
Patient profile
- 71 year-old male.
- Risk factors: Insulin treated diabetes, hypertension, hypercholesterolemia, former smoker.
- Presents with effort angina since several months. Treadmill stress test positive for myocardial ischemia.
Lesion type
- LAD with 70% stenosis in the proximal segment and a long, tortuous, calcified, chronic total occlusion in the middle segment.
- 100% severity (Figure 1).
Procedure
- With the help of Navitian antegrade wire escalation technique was used.
- An Asahi Fielder XT® and an Abbott Pilot® 150 were unable to cross the lesion (Figure 2).
- Asahi Gaia Second®, supported by Navitian, successfully crossed the CTO (Figure 3) and reached the true distal lumen. Navitian was pushed through this wire and also crossed the lesion immediately.
- Navitian passed to the distal vessel to exchange Gaia Second to Asahi Sion wire. Navitian was removed using the trapping technique.
- NC balloon was used, but was unable to dilate a focal calcified point in the middle segment (Figure 4). So, again, Navitian was passed to the distal vessel and the Sion® wire was exchanged for an extra-support RotaWire®. Rotablation was performed using 1.50 mm burr.
- After successful treatment, Navitian replaced the Rotawire for the Sion wire (Figure 5).
- Finally, three overlapping drug eluting stents were, consecutively, placed distal to proximal: 2.25x34 mm; 3.00x34 mm and 3.50x26 mm.
- An excellent final result was achieved with a widely patent vessel and TIMI 3 flow (Figure 6).
Conclusion
“Navitian microcatheter provides good support. In this particular case it was an excellent surprise to cross this long severely calcified CTO just after the wire, without predilatation. Navitian can be use in daily practise focus on antegrade CTOs, diffuse and calcified lesions in order to support to cross the occlusion and to exchange wires safely."
Dr. Alberto Rodrigues
Hospital CHGE, Gaia, Portugal
