Title
PCI of Anomalous LCX CTO
Introduction
A 49 year-old obese man with an anomalous left main originating from the right coronary sinus, was referred for a reattempt PCI of a left circumflex (LCX) artery chronic total occlusion (CTO). The procedure was challenging due to poor visualization related to large body habitus, difficulties with guide support and engagement due to the anomalous coronary artery origin, and lack of interventional collaterals.
Clinical Case
The patient was a commercial pilot, who underwent a stress test due to frequent PVCs. The nuclear perfusion stress revealed ischemia in the inferior and inferolateral walls. Coronary angiography revealed an anomalous origin of the left main artery from the right coronary cusp with a LCX CTO. After a failed attempt, the patient was subsequently referred to us for a reattempt. We obtained bilateral groin access (right femoral 8F, left femoral 7F). Coronary engagement was challenging. We attempted but failed to engaged the left main with an AL1 guide catheter, but had success with an AL 0.75 guide catheter. We had similar challenges with engagement of the RCA. We failed using AL1 and JR4 guide catheters, but succeeded with a hockey stick (6F) guide catheter. With the help of contralateral injection we attempted antegrade wire escalation (AWE) using a Corsair XS microcatheter and Fielder XTA guidewire, followed by a Gaia 2
nd. Given the large body habitus, visualization of the proximal cap was possible only by contrast injection through the microcatheter. During AWE, the Gaia 2
nd entered the subintimal space. The Corsair XS was advanced, and the Gaia 2
nd was replaced for a Miracle 3 guidewire (300cm). The microcatheter was removed and a Stingray LP balloon was advanced over the Miracle 3 wire. We attempted reentry using the double blind stick and swap technique using the a Gaia 3
rd wire to stick and a Pilot 200 to swap. The Pilot 200 was advanced into the distal true lumen. The Corsair was advanced and used to swap the Pilot 200 for a Sion blue wire (300cm). We then performed PTCA (using a 1.5x12 mm balloon) and IVUS. The vessel was 2 mm in diameter, diffusely diseased with <180 degree of calcium. We stented the LCX with a 2.25x30 and 2.5x40mm DES (Orsiro). We were unclear if a significant residual lesion was present at the distal stent edge in the distal LCX. This was seen better with the use of a guide extension catheter, and confirmed with contrast injection through the microcatheter. The distal lesion was treated with a 2.0x12 DES (Resolute), with an excellent final results.
Discussion
CTO PCI in anomalous coronary arteries can be challenging. The anatomical location of the coronary ostia can lead to challenges with guide engagement and support. Further, for CTO lesions with poor retrograde options, use of antegrade crossing strategies is preferred.