Complex coronary cases
Recanalization of prox RCA CTO In-stent Restenosis – June 2018

72 year old NIDDM male with prior CABG (2012) and PCIs presented with CCS Class III angina, dyspnea and right leg claudication. A SPECT MPI revealed moderate inferior and inferolateral ischemia. A Cardiac Cath on May 3, 2018 revealed 3 V CAD, in-stent restenosis CTO of proximal RCA (distal vessel fills via LAD collaterals), 80% proximal LAD, 80% proximal LCx and 95% proximal Ramus with occluded SVG to RCA, to Ramus and to LCx-OM1, patent LIMA to LAD and LVEF 60%. Patient underwent successful intervention of proximal LCx using DES (Xience Alpine 3x12mm) and PTCA of Ramus. Patient still has CCS Class II symptoms on GDMT including three antianginals. Patient is now planned for recanalization of proximal RCA CTO in-stent restenosis via antegrade or retrograde approach followed by Rotational or Excimer laser atherectomy and DES implantation.

Moderator: Sameer Mehta, MD


What made the CTO so easy to cross in today's case? Was the lesion easy or good technique with proper wire escalation?

Yes we were pleasantly surprised by the quick recanalization of the RCA CTO ISR which has been there since 2012 when pt had CABG and now the graft is occluded. It just needed Fielder guidewire to cross. We expected that much stiffer wires will be needed to cross but was rather it turned out to be an easy recanalization with just the Fielder wire.

Your present 3 wires for escalating with anterior approach?

Fielder (or Miraclebro 6) followed by Gaia-3 and then Confianza 12.

And for retrograde?

Fielder FC, Gaia-2 and then Confianza 9.

Regarding switching of anti-platelet, when would you expect this to be a part of the guidelines?

Antiplatelet therapy switch should be the part of new focused Interventional update to be published in late 2018 as has been suggested by the international consensus statement.

In what cases are you using Cangrelor?

IV Congrelor is used in 1) acute PCIs with issues about absorption of antiplatelet therapy (hemodynamics compromise, intubated, elderly pts with swallowing difficulty taking pills lying down), 2) pt undergoing or underwent PCI and needs urgent non cardiac surgery prohibiting use of P2Y12 inhibitors; 3) lastly pt who had high risk PCI and needs unexpected noncardiac surgery within 1-3 moths of the PCI.

During ELCA, where do you use saline and where do you use dye?

All cases of ELCA are done with saline flush to cause plaque vaporization except cases of unexpanded stents, where we use ELCA with contrast flush to cause explosion to break the Ca behind the stent struts.

In your ELCA use, are 0.9 and 1.4 the only catheters you use, or there has been use of larger catheters?

There are only 2 ELCA catheters; 0.9 and 1.4 mm for the coronay use.

Which case during your annual conference do you consider the best?

I believe case of TMVR was the best case of the CCVVC symposium 2018.

Which is more helpful education aid - your annual conference or the monthly cases?

By far the monthly CCClive webcast has much higher educational value then annual CCVVC as supported by the audience of 8-10,000 hits per month and its global reach in 132+ countries. But just to be complete, CCVVC has its own brand educational value because of packed multiple variety of live cases with didactic debates and comments by the national and international faculty.

Would the CME certificate be made available online and who will be the certifying agency? Is is possible to watch archived cases to obtain CME?

Yes starting July 2018, CCClive case will get 1.5-2 hrs CME credits to be given by the Icahn School of Medicine of MSH. Certainly it will require to go to the archived cases and answer 3 of the 5 questions correctly after watching the webcast.


Join the Discussion

2 thoughts on “Recanalization of prox RCA CTO In-stent Restenosis – June 2018”

  1. gasperetti says:

    thank you! very instructive .. and Congratulations on the conference it was great …and Congratulations to Dr. Kini !! there are people with gifts, but to combine unique skills and gifts with grace and a big heart is very rare…best wishes to you!

  2. triptideb says:

    excellent teaching

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