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Case 190: Manual of CTO PCI - Antegrade first

A patient with prior radiation therapy to the chest presented with cardiomyopathy and was found to have 2-vessel coronary artery disease with 70% proximal RCA stenosis and an ostial LAD CTO. She was turned down for CABG and referred for PCI. Right heart catheterization showed normal filling pressures. The RCA was successfully stented first keeping the guide catheter disengaged due to severe pressure dampening. We considered upfront retrograde crossing due to proximal cap ambiguity but we did dual injection in multiple projections to determine the origin of the LAD and also performed IVUS. There appeared to be an entry point into the LAD CTO. A Fielder XTA failed to cross, however a Pilot 200 successfully crossed into the distal true lumen as confirmed by contralateral injection. There appeared to be disease or dissection in the proximal circumflex, hence the left main bifurcation was stented using the DK crush technique with an excellent result. Delivery of equipment to the SB was challenging after rewiring but was successfully completed using the side branch anchor technique.