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Complex Ostial LAD CTO: Saphenous vein Graft as an Option for Retrograde Approach

Case of the month: July 2019

This didactic procedure  concerns a patient with history  of CAD : CABG ( Saphenous vein to the Diagonal-LAD), presenting severe symptomatic severe stenosis of the distal Graft anastomosis and Ostial LAD CTO, he has underwent  successfull retrograde recanalization through the Saphenous vein & Stenting with good final result.


Educational objectives

  • Different options to approach patients with native vessels CTO & CABG.
  • Retrograd native vessel CTO  recanalization through saphenous vein Graft.
  • How to approch bifurcations in CTO lesions.
  • How to perform TrapLiner assisted Reverse-CART technique.
  • Dual Lumen microcatheters in CTO procedures.
  • IVUS for guidance & optimization during complex CTO procedures.

Step-by-Step Procedure

  • Double Femoral 8F Access with 45cm long sheaths.
  • EBU 3.75 8F into the LM & AL1 8F into the Saphenous vein graft.
  • Workhorse wire Sion blue (Asahi) into the distal Left Circumflex.
  • First Antegrade approach using Gaia 2 guidewire (Asahi) & Corsair Pro microcatheter (Asahi).
  • Workhorse guidewire Sion Blue into the Saphenous vein Graft distal to the LAD.
  • Advancing a second microcatheter Caravel (Asahi) into the distal Vein Graft near the distal CAP.
  • Trapping the Antegrade microcather using a TrapLiner (Teleflex).
  • Predilatation of the proximal CTO segment with a 2.0 Sequent (Braun) Balloon to facilitate the TrapLiner Reverse-CART technique.
  • Performing Antegrade Knuckle wire with Miracle (Asahi) to be sure being in the vessel.
  • Performing TrapLiner assisted Reverse-CART technique using 3.0x20mm Sequent (Braun) Balloon and Gaia 3 guidewire (Asahi).
  • Externalization of the RG3 guidewire(Asahi).
  • Advancing a dual lumen microcatheter Fine Duo (Terumo) antegradely toward the diagonal.
  • Crossing the lesion antegradely toward the LAD using the dual Lumen microcatheter & a Workhorse Guidewire Sion Blue (Asahi).
  • Predilatation of the CTO.
  • IVUS evaluation.
  • Long Stenting from the Left Main to the Mid LAD with overlapping Stents: Coroflex ISAR Neo (Braun).
  • IVUS evaluation & Optimization.
  • Final result.
  • Access Closure using Angioseal 8F Closure device.


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