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Percutaneous coronary intervention of a left anterior descending chronic total occlusion using an epicardial collateral retrograde approach,Dr Patricia HT Hon Dr David CK Hu,CTO-LAD retrograde approach,59 yo male exertional angina March 07 Risk factors: hypertension, hyperlipidaemia, new onset Type 2 DM and smoking occasionally,CTO-LAD retrograde approach,CTA coronary angiogram: severe and extensive disease shown in RCA and LAD LV function satisfactory on echocardiogram,CTO-LAD retrograde approach,Diagnostic coronary angiogram March 07: CTO mid LAD, severe proximal disease, good collateral retrograde filling from RCA Severe disease distal LCX, sub-total occlusion (TIMI-2) 90% lesion mid RCA and 50% disease PDA,CTO-LAD retrograde approach,Management plan: PCI to RCA + surgical stand-by (high risk) Staged revascularisation to CTO-LAD and LCX either surgically or by PCI,CTO-LAD retrograde approach,March07: mid RCA stented successfully (Xience V 3.5mm x 23mm),CTO-LAD retrograde approach,Exercise nuclear perfusion scan 3 weeks after stenting of mid RCA: No significant ischaemia in LAD territory. Frequent PACs noted during exercise Option of revascularization of LCX and CTO-LAD or conservative therapy: patient chose latter,CTO-LAD retrograde approach,Enjoyed long periods of exercising vigorously without anginal symptoms Nov 07: recurrence of chest discomfort and developed paroxysmal AF New ST depression on exercise treadmill,CTO-LAD retrograde approach,Restudy coronary angiogram Nov 07: Patent RCA stent New lesion 80% proximal RCA LAD and LCX disease as before,CTO-LAD retrograde approach,Adhoc stenting to new lesion proximal RCA (Endeavor 3.5mm x 18mm) Sub-total occlusion LCX stented (Endeavor 2.25mm x 14mm) Attempted but failed to re-open CTO-LAD in antegrade approach,CTO-LAD retrograde approach,Options: PCI to CTO-LAD using retrograde approach vs CABG using LIMA to LAD (dual anti-platelet therapy),CTO-LAD retrograde approach,Jan08: PCI to CTO-LAD using RCA-epicardial collateral retrograde approach,CTO-LAD retrograde approach,Bilateral femoral artery puncture 6F XB-LAD 3.75 catheter LAD 7F AL-1 catheter to RCA,CTO-LAD retrograde approach,Microcatheter (Ichiban-Yari, Japan) Guidewire (Fielder, Asahi Intecc, Japan) Successfully crossed the CTO-LAD through RCA collateral Positioned in proximal LAD,CTO-LAD retrograde approach,Guidewire docked Multiple balloon dilatations (Lacross) from distal lumen to proximal lumen Antegrade Fielder wire passed into distal LAD 3 stents (Endeavor 3 mm x 18mm, 2.75 mm x 24mm, 2.5 mm x 30mm) deployed successfully,CTO-LAD retrograde approach,Primary stenting (Xience V 2.5 mm x 18mm) to PDA peformed,
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