Case 167: Manual of PCI - CTO PCI techniques for a wire uncrossable lesion

A patient was referred for PCI of a right coronary artery subtotal lesion after failure to cross the lesion with a guidewire. The lesion was eccentric and heavily calcified. Antegrade wiring with a microcatheter and polymer-jacketed (Fielder XT-A, Sion black) and intermediate tip stiffness (Gaia Next 2) guidewires failed. A Sion black was advanced into an acute marginal branch at the proximal cap followed by “open sesame” without success. Eventually a Gladius Mongo wire was advanced across the mid RCA lesion in the extraplaque space, followed by re-entry into the distal true lumen using the Stingray balloon and the “stick and swap” technique. A nice result was achieved after stenting both angiographically and by IVUS (the stent had oval shape at the calcified vessel segment).

[@shangz0216]

Thanks for the educative case presentation.

[@komedim1928]

Thanks manos

[@NikhilJha89]

What about Retrograde approach?

[@manosbrilakis]

This is another option - we typically use it as last resort after antegrade attempts fail, since going retrograde has higher risk of complications.