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LAD CTO: Retrograde Approach with IVUS Guidance

Case of the Month: June 2018

This didactic procedure concerns a 63 y.o male, with  medical history of CAD (Lcx already treated few months before, LAD CTO JCTO Score:4).

First attempt of LAD recanalization  has failed, The patient is still symptomatic  despite OMT.

The second attempt was a success with retrograde approach using IVUS guided retrograde puncture.

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Educational objectives

  • How to approach patients with Symptomatic coronary  chronic total occlusions.
  • Optimal Application of the Hybrid algorithm in treatment of coronary CTO.
  • Evaluation of the anatomical complexity of coronary CTO with combined angiography and IVUS.
  • IVUS usefulness to decide strategy in coronary CTO procedures.
  • Step by step retrograde approach in coronary CTO procedures.
  • IVUS guidance for safe retrograde and antegrade punctures.
  • How to optimize sizing and stent implantation in Coronary CTO procedures.

Step-by-Step procedure

  • Double Femoral approach 7F introducers.
  • EBU 3.5 7F to the Left system and AL0.75 7F to the right system with two Sion blue wires for stabilization.
  • IVUS assessment of the LAD Poximal CAP.
  • Retrograde approach with Corsair microcatheter and surfing technique via PDA-septal connections using a Sion black guidewire.
  • IVUS evaluation of the  retrograde wire position.
  • Retrograde puncture of the proximal CAP using a Confianza Pro 12 guidewire.
  • IVUS evaluation of t the Confianza Pro12 wire confirming subintimal position in the Proximal LAD.
  • Antegrade puncture using a Confianza Pro12 and Finecross microcatheter.
  • Progession antergradelly using Finecross microcatheter and Sion black wire.
  • Confirming the distal position with safe Tip injection.
  • IVUS evaluation of the antegrade wire and LAD sizing.
  • Retrograde material remove.
  • Predilatation and stenting of Ostio-proximal LAD with Promus 3.0x32mm DES.
  • Stenting of the Mid-LAD with Promus 2.5x24mm.
  • Final angiographic and IVUS control and Optimization.

Biobliography



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