The challenges in Cath lab: CTO case presentation QUANGNINH PROVINCIAL GENERAL HOSPITAL TRẦN QUANG ĐỊNH,MD Quangninh provincial general hospital.

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1 The challenges in Cath lab: CTO case presentation QUANGNINH PROVINCIAL GENERAL HOSPITAL TRẦN QUANG ĐỊNH,MD Quangninh provincial general hospital

2 BACKGROUD Male pt 81 y/o. Risk factor: Hypertension, Ex smoker. History: Chest pain, dyspnea 2 months. Admission: Chest pain CCS 3.

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4 BACKGROUD Blood test: renal, cardiac biomarkers in normal range. Echo: Reduction of anterior wall motion and LVEF 50%, Dd 50 mm, Ds 37 mm.

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6 LAD CTO – Stenosis LCx II 70% and collateral circulation from OM II to LAD

7 LAD CTO and collateral circulation from LCx to PLV and PDA of RCA

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11 REVASCULARIZATION On EKG we do not see Q wave, so the cardiac muscles are alive. Ischemic burden > 10%. BUT patient and also surgeon refuse CABG Choose the intervention

12 THE REASONS TO ACCEPT THIS CASE Proximal cap: Unambiguous Distal vessel quality: fair Collaterals: epicardial CTO segment: long > 20 mm ANTEGRADE: wire escalation

13 CHOOSE Introduction: Radial artery (collateral circulation from LCx to LAD) Antegrade Wire escalation (length < 20 mm maybe) Crossboss-Stingray: No Reverse CART: No

14 Start with guide wire Sion blue, then Runthrough Hapacode

15 Then Gaia second

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17 Test contrast microcatheter

18 Change Gaia second by Sion blue

19 Introduce ballon Tazuna 1.25 x 15 mm

20 Dilate by ballon Tazuna 1.25 x 15 mm

21 LAD appears surprisingly

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23 Continue to dilate the Diagonal I by Emerge 2.0 x 20 mm

24 LAD appear more clearly

25 BUT LAD disappear quicly post-dilate

26 WE HAVE CHANCE

27 BUT not easy, WRONG WAY?

28 Dilate the bifurcation with ballon Emerge 2.0 x 20 mm

29 True way of LAD

30 LAD more clear

31 Stent Promus 2.5 x 32 mm

32 BUT…TRAP… Unstable lesion just behind 1rd stent

33 Put the 2 nd stent Biofreedom 2.5 x 18 mm.

34 The 2 nd stent covered LAD II.

35 Change guide wire and up the ballon Diagonal I.

36 Put the 3 rd stent Biofreedom 2.5 x 24 mm and preparation 1 ballon Tazuna 2.5 x 20 mm for kissing ballon.

37 Up ballon of 3 rd stent

38 Kissing ballon

39 And kissing ballon 2 nd time

40 Post kissing ballon

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44 Surprise BEFORE AFTER

45 LESSON: SO THE FINAL RESULT IS GOOD BUT First case of CTO BUT not only CTO, there’s more Bifurcation (more complicated). Collateral circulation of First Diagonal (not common). DO NOT LOSE HOPE. You never know what CTO bring.

46 THE QUESTION In case of subintimal wiring, the size of ballon we should use for CART technique?

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