Case 295: Manual of CTO PCI - HDR to the rescue

A patient with 3-vessel coronary artery disease (CTO of the proximal LAD and the proximal RCA and 90% proximal circumflex) was referred for PCI after being turned down for CABG due to a prior stroke. Left ventricular ejection was 45% with viability in all myocardial territories. We decided to recanalize the proximal circumflex and the LAD CTO. We inserted an Impella CP device through right femoral access (single access technique). The circumflex was wired and predilated. Aortic pulsatility was lost with every balloon inflation. We used a SuperCross 120 microcatheter and a Gaia Next 2 wire to enter into the LAD occlusion. We tried to knuckle a Gladius Mongo and a Fielder XT guidewire without success. We did HDR (hydrodynamic recanalization), followed by advancement of a Gladius Mongo wire into a septal branch. Surfing of the branch and contrast-guided attempts failed to cross the septal. Another Gladius Mongo was knuckled to the mid LAD, followed by multiple unsuccessful attempts to re-enter with a Stingray balloon and multiple guidewires. We decided to stop the procedure and contemplated doing investment. As a last attempt we redirected the Sion black wire that was in the septal branch and it went into the diagonal. Using this wire and a Sasuke microcatheter we advanced another wire into the septal. Eventually using a Sasuke microcatheter over the septal wire, a workhorse wire was advanced into the true lumen in the distal LAD. The LAD and the circumflex were successfully stented using the DK crush technique.