Athanasios Rempakos, MD, Minneapolis Heart Institute Foundation, Minneapolis, MN
Judit Karacsonyi, MD, PhD1, Salman S. Allana, M.D., FSCAI2, Spyridon Kostantinis, MD3, Baha Simsek, MD1, Athanasios Rempakos, MD1 and Emmanouil S. Brilakis, MD, PhD, FSCAI3, (1)Minneapolis Heart Institute Foundation, Minneapolis, MN, (2)The University of Texas Southwestern Medical Center, Farmers Branch, TX, (3)Minneapolis Heart Institute® - Abbott Northwestern Hospital, Minneapolis, MN
Keywords: Chronic Total Occlusion (CTO)
Title: Double Stingray Introduction: Right coronary artery (RCA) chronic total occlusion (CTO) percutaneous coronary intervention (PCI) was attempted for a patient with medically refractory angina and reversible ischemia on dobutamine stress echocardiogram. Clinical Case: A 61-year-old man presented with medically refractory angina. He had a history of hypertension, prior smoker and strong family history of coronary artery disease. Coronary CT revealed CTO of the mid part of RCA and 50-60% stenosis in mid LAD. Echocardiography showed normal left ventricular ejection with no wall motion disorders. On dobutamine stress echocardiogram reversible ischemia in the inferior and inferolateral wall was seen. Antegrade wiring was attempted with a Fielder XTA wire and Caravel microcatheter (MC), entering the acute marginal branch. Intravascular ultrasound was used to resolve proximal cap ambiguity, but the significant calcification hindered the process. Sion Black and Caravel MC entered the extraplaque space in the mid RCA and wire was switched to Gladius Mongo proceeding to the distal RCA. A Stingray balloon was delivered with a TrapLiner and several guidewires were used with the double blind stick and swap and bobsled techniques, however we could not re-enter. We decided to switch to retrograde approach first through septal collaterals but the Caravel could not follow the wire. An epicardial collateral was attempted next from the circumflex, but the Suoh 3 kept entering the posterolateral (PL) branch and could not be redirected to the distal RCA even with Sasuke and SuperCross 120 MC. We switched back to antegrade re-entry crossing attempts with the Stingray balloon again but it wasn’t successful. With the Sasuke MC we could enter the PL and repeated the Stingray re-entry attempts, finally successfully crossed to the true lumen of the PL. After several guidewires and Stingray attempts the wire entered into the PD true lumen as well. DK crush bifurcation technique was performed with 3 drug eluting stents (DES), followed by additional 2 DES in mid and proximal RCA. Angiography revealed TIMI 3 flow and well expanded stents. Discussion: Persistence and switching between strategies can be vital for success in CTO PCI. Dual lumen microcatheters facilitate wiring bifurcations and steep angles. In case of a bifurcation at distal cap double re-entry may be required.