A Retrograde Approach via Ipsilateral Septal Collateral Channels in LAD-CTO Intervention
Anthony Teta, MD, McLaren Healthcare/Macomb/Michigan State University Program, Mount Clemens, MI
Anthony Teta, MD, McLaren Healthcare/Macomb/Michigan State University Program, Mount Clemens, MI, Dr. Lakshmi Gloria Rao, DO, McLaren Macomb, Clinton Township, MI, Sabina Kumar, DO, Michigan State University, Mt Clemens, MI, Anvita Suneja, OMS-II, Michigan State University, Detroit, MI, Arjun Chadha, MD, McLaren Macomb, Canton, MI and Michael Blair Deyoung, D.O., McLaren Macomb, Mount Clemens, MI
Title
A Retrograde Approach via Ipsilateral Septal Collateral Channels in LAD-CTO Intervention Introduction
There is a growing interest in chronic total occlusion (CTO) PCI, highlighting the importance of a CTO operator’s ability to utilize less common revascularization approaches. We describe a unique CTO case where the ipsilateral septal collaterals were used for revascularization via a retrograde approach after an attempted antegrade approach failed. Clinical Case
A 61-year-old man with a past cardiac history of hypertension, hyperlipidemia, and prediabetes initially underwent diagnostic coronary angiography after an abnormal stress test, to evaluate CCS III angina. Diagnostic coronary angiography demonstrated a CTO of the mid-LAD (J-CTO score of 1) and 80% stenosis in the midportion of the PDA. Utilizing a Heart Team approach, the decision was made to attempt CTO intervention. Arterial access was achieved under ultrasound guidance via the right femoral artery utilizing an 8 French sheath. The left main coronary artery was successfully engaged with a 7 French EBU 3.5 guide catheter. Initially, attempts were made via an antegrade approach however we were unsuccessful. The decision was then made to proceed with a retrograde approach utilizing ipsilateral septal to septal collaterals. A Corsair® catheter and PROWATER® wire were advanced to the septal perforating branch. The PROWATER® wire was exchanged for a SION® black coronary wire while maintaining the Corsair® catheter. Successful retrograde crossing of the mid-LAD CTO was performed after the SION® black wire crossed the ipsilateral septal to septal collaterals into the LAD, followed by retrograde advancement of a 330 cm Asahi® RG3 0.010 in guidewire. Successful angioplasty with a 2.5 mm x 20 mm compliant TREK™ balloon was achieved via an antegrade approach. A PROWATER® wire that remained in the diagonal branch was withdrawn and placed into the distal LAD. PCI over the antegrade PROATER® wire was achieved with successful implantation of overlapping 2.5 mm x 38 mm and 3.0 mm x 28mm Xience Skypoint™ stents. Serial post-dilation of the distal stent followed by the proximal stent with a 2.5 mm x 20 mm noncompliant (NC) TREK™ balloon at high pressures, then a 3.0 mm x 15 mm NC TREK™ balloon at nominal pressures. Post-intervention angiography demonstrated no residual stenosis and TIMI-3 flow throughout the LAD and associated branches. An 8 French ANGIO-SEAL® closure device achieved right femoral arterial hemostasis. He tolerated the procedure well and was discharged home the following day. Discussion
CTO PCI carries an increased risk of known PCI complications, increased overall procedural time, contrast, radiation exposure, and a high percentage failure rate due to the inability to cross the lesion. Severe tortuosity of the collateral channels limits the success of a retrograde approach; and therefore, utilization of interseptal collateral channels in retrograde procedures is rare. Understanding critical angiographic parameters in assessing CTO PCI planning, common treatment algorithms, and standard techniques can help operators bailout to alternative revascularization strategies. After unsuccessful initial antegrade attempts, a retrograde approach can be undertaken to successfully revascularize a CTO of the LAD via ipsilateral septal collaterals.