06 Aug Understanding Simple RCA CTO: A Complex Journey | Dr.Sharath Reddy
The management of coronary artery disease often involves complex procedures, particularly when dealing with chronic total occlusions (CTOs). This blog will delve into a case study involving a simple RCA CTO that unexpectedly turned into a challenging scenario. We will explore the patient’s background, the procedural challenges faced, and the lessons learned from this experience.
Patient Background
The patient in this case is a 51-year-old male who is a smoker and has a family history of premature coronary artery disease (CAD). His medical history includes a percutaneous coronary intervention (PCI) with stenting to the left anterior descending artery (LAD) and obtuse marginal (OM) artery. He presented with class III angina that had persisted for six months.
Upon examination, his left ventricular function was normal. Coronary angiography revealed a mid lesion in the RCA and a previously treated mid lesion with a cutting balloon due to myocardial bridging. This situation set the stage for the planned RCA intervention.
Initial Assessment and Imaging
A coronary angiogram of the right coronary artery (RCA) showed total occlusion at the ostium. The left coronary system displayed signs of a previously treated lesion. The imaging also indicated clear bridging collaterals from the RCA, which is an important aspect of the case.
CT angiography revealed a short CTO segment with minimal calcium within the CTO area, although some calcification was noted in the vessel wall. The presence of a bridging collateral suggested that it might be a vasa vasorum supplying the distal RCA, which would be crucial for planning the intervention.
Understanding the JCT Score
The JCT score for this patient was assessed as zero, indicating a straightforward case with a short CTO, a clear cap, and minimal angulation. This score is essential as it helps guide the approach to the intervention.
Wiring Strategy: Antegrade Approach
Given the favorable conditions indicated by the JCT score, the initial strategy was to proceed with antegrade wiring. The clear cap and visible distal vessel suggested that this approach would be effective.
However, one challenge identified was the lesion proximal to the CTO. It is generally advisable to treat inflow lesions before attempting to cross CTOs to facilitate smoother interventions. This is critical to avoid complications during the procedure.
Complications During Antegrade Wiring
During the antegrade wiring process, a Fielder XTR wire was utilized to navigate the tight lesion. Unfortunately, the wire ended up in the subintimal space, creating a significant complication. This misstep obscured the previously clear track and complicated further attempts at antegrade wiring.
Faced with this unexpected situation, the team had to pivot to a retrograde approach. This shift highlights the importance of being prepared for complications that can arise during interventions.
Transitioning to Retrograde Wiring
For the retrograde approach, the team chose to utilize the first septal branch. Using a combination of wires and a Caravel microcatheter, they successfully crossed into the RCA.
Identifying the Distal Cap
Upon reaching the distal cap, the team performed an injection to clarify the location of the cap. Although initially ambiguous, the distal cap became more defined, allowing for further progress in the retrograde wiring process.
Successful Crossing and Externalization
Using the Gia 2 wire, the team successfully crossed the CTO segment. The flexibility of the Gia 2 wire allowed for better navigation compared to the Fielder XTR. This adaptability proved essential in overcoming the challenges presented by the CTO.
Once the wire was navigated into the aorta, it was directed into the antegrade guide for externalization. This step is critical for proceeding with the intervention after successfully crossing the occlusion.
Stenting the RCA
After externalization, the RCA was pre-dilated with a 2 mm balloon. Following this, the team performed intravascular ultrasound (IVUS) to assess the vessel and the stent placement.
Assessment of Branches and Collaterals
IVUS revealed two branches of interest, one of which appeared to have a small flap that raised concerns about potential flow issues post-stenting. The other branch showed good flow, indicating a favorable outcome for that segment.
The bridging collaterals identified earlier were also assessed. These collaterals, which appeared to be expanded vasa vasorum, played a significant role in the blood supply to the distal vessel.
Final Outcomes and Results
The final result of the RCA after stenting was satisfactory, with good flow and expansion observed. The stent areas showed promising reference measurements, indicating successful intervention.
Key Takeaways from the Case
This case serves as a reminder that what may initially appear to be a simple CTO can evolve into a complex situation. Here are some key lessons learned:
- Simple cases can become complex unexpectedly.
- Preparation for all possibilities is crucial.
- Treat inflow lesions before crossing CTOs.
- Be ready to switch strategies when complications arise.
- Understand the implications of subintimal wiring.
- Use appropriate wires for challenging lesions.
- Evaluate collateral circulation carefully.
- Employ IVUS for optimal stent placement.
In conclusion, this case highlights the dynamic nature of interventional cardiology and the necessity for adaptability in approach. Each procedure is unique, and understanding the potential challenges can significantly impact the success of the intervention.
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