Case 311: Manual of CTO PCI - Calcified proximal cap

A patient presented with dyspnea on exertion and was found to have a CTO of the mid RCA. After failure of medical therapy, he was referred for RCA CTO PCI. Coronary CT angiography showed a heavily calcified proximal cap, short occlusion length (6.5 mm) and good quality distal vessel. Distal filling was mainly via ipsilateral collaterals. Antegrade wiring attempts failed. An IVUS catheter could not be advanced into an atrial branch originating at the proximal cap. Retrograde crossing attempts also failed to cross several septal collaterals. During repeat antegrade crossing attempts a knuckled Mongo wire was advanced past the proximal cap, but no equipment could follow. We did the side BASE technique (balloon inflated halfway into the atrial branch at the proximal cap and halfway into the mid RCA) and a Mongo wire was knuckled past the proximal cap. The microcatheter followed easily. Re-entry was achieved with the Stingray and a ReCross microcatheter. The distal vessel could not be visualized with contralateral injections, but IVUS confirmed distal true lumen crossing. After stenting a distal vessel perforation was observed that was successfully sealed with a 2mmx4cm Axium coil. There was no pericardial effusion.