Case 268: Manual of CTO PCI - HDR: HydroDynamic contrast Recanalization

A patient was referred for PCI of a circumflex in-stent CTO. Antegrade wiring with a Gaia Next 2 wire failed. HydroDynamic contrast Recanalization (HDR) was performed: the tip of the microcatheter was advanced into the proximal cap, followed by injection of 1 ml of contrast. Following contrast injection a Fielder XT-R successfully crossed into the 2nd obtuse marginal branch. A microcatheter could not be advanced but this was eventually successful after using a LiquiID guide extension and a 1.5 mm Takeru balloon. IVUS was used to localize the ostium of the first obtuse marginal branch. A blocking balloon was inflated distal to the OM1 origin, allowing insertion of a Gaia Next 2 wire into the OM1, but there was no antegrade flow despite balloon inflation. A Fielder XT was knuckled further down into OM1 restoring antegrade flow. HDR was repeated in the distal circumflex but led a a wide fixed contrast “stain”. No further attempts to cross the distal circumflex were made. A nice final result was achieved after balloon angioplasty of the circumflex and OM1/OM2.