Case 259: Manual of CTO PCI - Ultra low contrast CTO PCI

A patient with prior CABG and stage IV chronic kidney disease (CKD) presented with NSTEMI and was found to have occlusion of the SVG-PDA and the native mid right coronary artery. He was turned down for CABG and referred for PCI of the RCA CTO. A primary retrograde approach was used through the occluded SVG-PDA that was successfully crossed with a Gladius Mongo through a Corsair Pro microcatheter as confirmed by tip injection through the microcatheter. The retrograde and an antegrade guidewire were advanced to the mid RCA, followed by successful guide extension reverse CART but the neither a microcatheter nor a balloon could cross the mid RCA in either antegrade or retrograde direction. The retrograde wire was retracted and a Rotawire Drive Floppy was advanced antegradely to the distal RCA followed by rotational atherectomy of the mid RCA. Repeat reverse CART was successful, as was advancement of the retrograde microcatheter into the antegrade guide, that was followed by externalization of an R350 guidewire. Preparation of the RCA required rotational atherectomy of the distal RCA and well as intravascular lithotripsy that were both guided by IVUS. IVUS-guided stenting was performed with a single final angiographic injection showing an excellent stenting result. Only 12 ml of contrast were used for the entire case.

[@ivankoshkin837]

I guess it is just true to true crossing. Otherwise even for directed Reverse-CART small balloon would have been used to cross retrogradely through that space. Moreover it is too dangerous to rota being subintimal. Interesting what IVUS showed? Great case, thanks! 👏🏻

[@shangz0216]

Thanks for the excellent case presentation.

[@Hanin243]

Nicely done 👍, interestingly how quite often it’s not too challenging to wire chronically occluded graft and use as retrograde route thanks

[@indiechique2059]

I would say that in ckd esrd there’s not much to save in kidneys, just do dialysis post procedure and you’ll be fine. Yes this technique holds true in Aki where we want to save kidneys. Many authors are of view that contrast doesn’t worsen kidney functions, usually it’s due to plaque embolisation

[@muhammadyolandisumadio1547]

It seems that you dont need the retrograde approach. Since your filder xt a and rota wire and even rota can pass antegradely.
Why need to reverse cart then?

[@Miguel-mb9xt]

Why attempting retrograde, if it was demonstrated that it was a chronic oclussion of the graft?