Case 171: Manual of CTO PCI - Longest case

A patient with severe peripheral arterial disease in need of peripheral artery revascularization was referred for multivessel PCI: he had an ostial LAD CTO, distal left main and ostial circumflex lesions and a mid right coronary artery lesion. His ejection fraction was 48% by cardiac MRI with viability of most myocardial territories. We obtained right femoral and right radial access. We were unable to engage via radial access and obtained left femoral access. PCI of the RCA was challenging due to severe tortuosity and calcification. After orbital atherectomy, predilation and use of a 6 Fr guide extension the mid and proximal RCA were successfully stented. A primary retrograde approach was followed for the LAD CTO given distal left main and ostial circumflex disease and proximal cap ambiguity. Retrograde crossing was challenging but succeeded using various guidewires (Suoh 03, Sion black, Fielder XTR). We could not advance a Corsair XS to the LAD but were able to advance a Turnpike LP and did tip injection. We advanced a guidewire subintimally to the proximal LAD clarifying the proximal cap ambiguity, followed by LAD antegrade subintimal wiring with a Gaia 3rd. We had difficulty advancing the 6 Fr Telescope to the proximal LAD despite multiple balloon dilations and the tip broke off. We were unable to retrieve it using the small balloon technique. We inflated a 2.5x8 mm balloon and pulled back the wire and the lost fragment that bounced off the left femoral sheath and embolized in the iliac artery. We advanced a Guidezilla into the LAD and completed guide extension reverse CART followed by externalization of an R350 guidewire. The patient developed chest pain and ST elevation. Angiography showed a filling defect in the distal RCA distal to the prior stents. We tried to deliver a stent but had stent loss. The stent was deployed. The tip of the guide extension also fractured. We have extreme difficulty advancing equipment through the mid RCA but after using multiple balloons and another guide extension we successfully delivered and deployed stents distally. We used a Sasuke to wire the mid LAD, followed by removal of the externalized guidewire. The left main, LAD and circumflex were successfully stented using the DK crush technique. An area of staining in the mid LAD was covered by a PK Papyrus covered stent. Additional stents was placed distally in the mid LAD and in the left main ostium. After completion of the PCI the lower extremities appeared cool, hence vascular surgery evaluation was requested without finding any new peripheral arterial lesions. The femoral sheaths were removed and manual pressure was held, but the patient developed a right groin hematoma followed by hemodynamic collapse requiring intubation and CPR. He was subsequently placed on VA-ECMO after obtaining repeat left femoral arterial access. Coronary angiography showed patent vessels. A graft was sutured in the right iliac artery and the arterial cannula was changed to the right groin. The patient was subsequently decannulated and extubated. He had normal ejection fraction and was neurologically intact and was eventually discharged to rehabilitation.