Complex coronary cases
Complex PCI of 20 year old multiple CTO Lesions of RCA – July 2019

Case and Plan

82-year-old female with NIDDM and prior CABG (1998) & PCI’s presented with CCS Class III angina and high-risk positive stress MPI for multivessel ischemia and normal LV function. A Cardiac Cath on May 21, 2019 revealed III Vessel CAD with totally occluded mid-distal RCA, prox LAD and LCx-OM1, 90% native distal LAD with patent LIMA to LAD, and patent SVG to OM1 and occluded SVG to RCA. Patient underwent DES PCI of distal LAD via LIMA. Patient still has Class II angina on MMT. Patient is now planned for PCI of multiple CTO lesions of RCA (>20 years old) guided by contralateral injection.

Of the many micro-support catheters you mentioned for CTO, which are your top 3?

1st-Finecross, 2nd-Corsair, 3rd-Turnpike.

And your present favorite?

Finecross overall performs very well in most situations and is the favorite of all micro-catheters at our hospital.

What is your present wire escalation strategy?

Gaia-2, Gaia-3 and then Confianza-9 and lastly Hornet-20.

Based upon the new data you presented regarding Radial route for CTO, would you do this case via the radial route?

Today’s case with J-CTO score of 4 will fall into the complex category and hence will not do this case with Radial access. Yes radial access will be ok to be used for the contralateral injection. That is what we usually do in complex CTO cases; Rt FA for main CTO access and Lt Radial for contralateral injection.

Do you favor a reentry strategy for CTO?

We categorically have not been advocating re-entry strategies (STAR, LAST) as most of the published data have shown higher peri-procedural MI rates and restenosis with re-entry strategies.

What would you feel with be the outcome of this procedure short and long-term?

This pt had excellent results of CTO RCA but we were able to retrieve only one branch (RPL) with RPDA still occluded. Hence, we plan to bring this pt back after 3 mths to evaluate RCA PCI patency and re-try RPDA recanalization if suitable angiographically.

Are you planning to do anything for the PDA?

Yes at the 3M follow-up to re-access RPDA via RCA stent struts, only if an antegrade channel is seen.

Will you begin using the CASTLE criteria in your practice?

I am not sure yet as we will do our own analysis form MSH database, to evaluate if new CASTLE criteria is really better then J-CTO score (which we routinely use and report in our PCI report).

Is it not confusing to have two CTO criteria?

I agree 2 CTO criteria will be confusing and I strongly believe that it is not necessary to start using CASTLE criteria until few other published reports proves its superiority over J-CTO score prediction.

Have CTO success rates in the U.S. become as good as those from our Japanese colleagues?

CTO success in USA also now has become over 92% routinely similar to Japanese data (based on CTO registry and Expert-CTO trial). I guess only difference could be the CTO complexity being done in USA vs Japan; more complex and higher J-CTO score for Japanese pts vs USA pts.


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One thought on “Complex PCI of 20 year old multiple CTO Lesions of RCA – July 2019”

  1. Dr Samiullah says:

    Indeed a nice case, very well done.. i have one query about the case, and i would like to please find some time to comment.
    the use of NC balloon, which was needed in this case i think.. but the operator didn’t go for it. would u please give a reason for it. thanks
    Dr Samiullah
    Fellow interventional cardiology
    NICVD Karachi Pakistan

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