2024 Scientific Sessions

73-year-old male was admitted for a planned second attempt of PCI CTO LCX procedure due to history of chest pain during exertion. His past medical history includes ischemic cardiomyopathy (LV EF of 35%), arterial hypertension, hypercholesterolemia, chronic kidney disease and peripheral arterial disease. A significant degree of reversible ischemia of the inferolateral wall was confirmed by myocardial scintigraphy since the patient had left-dominant coronary circulation.

Due to several high-risk features (comorbidities, CTO J-score 3, moderately reduced LVEF) the procedure was considered as CHIP PCI. Therefore, prophylactic mechanical circulatory support with pVAD (iVAC 2L™ by Pulsecath) was inserted through right femoral approach (17Fr). Left femoral access was used for coronary access (EBU 4,0 8Fr). We started with antegrade wire escalation (Fielder XT-a, Gaia 2^nd and 3^rd) but due to blunt stump and the bifurcation with OM branch on the level of occlusion the wires were prolapsing into the OM branch. Therefore, we switched to retrograde approach through LAD septal collaterals. At first, we were unsuccessful and perforated a small septal collateral. We found another septal collateral with Sion black wire followed by Turnpike LP Catheter bringing it all the way to the distal cap. However, several wires were introduced subintimally after crossing the proximal cap, despite the tip injection at the level of proximal cap confirmed the correct position of the microcatheter. We managed to cross all the way to left main and aorta with retrograde wire Gaia 2nd but as subintimal position was suspected we decided to introduce another guide (EBU 3,75 7Fr) and guide extension to LM through right radial approach. Then we slowly pulled back the retrograde Gaia 2nd and managed to introduce it into the guide extension near the proximal cap. We then introduced the retrograde wire into antegrade microcatheter with the tip-in technique, progressed with anterograde microcatheter while removing the retrograde one. Thus, procedure was switched to anterograde approach, ballooning and stenting the LCX with two DES, achieving good angiographic result. The patient was stable and angina free, pVAD was removed immediately after the procedure.