2025 Scientific Sessions

Title:
CTO Techniques in Non-CTO Cases

Introduction:
55 yo F with CAD s/p CABG with a LIMA to LAD, but no graft to Lcx who presented with CCS III found to have sever distal LM, ostial Lcx and ostial LAD stenosis.

Clinical Case:

• LM plaque orientation with retroflex circ making wiring of circ very difficult
• We attempted to wire antegrade but only got into LAD and ramus, unable to wire into Lcx
• Attempted reverse wiring with Sion Black which went subintimal and closed the vessel and we were unable to wire it
• She remained stable without CP which suggested collateral were present, we engaged a second guide in the LM (ping pong guide) and we found a diag to OM epicardial collateral which we were able to wire with a Suoh
• Due to the plaque orientation we were unable to wire from LCx into LM (same as we were unable to wire from LM to LCx)
• We attempted reverse CART in the proximal OM however were unable to make connection
• We attempted to stingray in the proximal LCx but were unable to connect, we suspected this was because this was in the area of reverse CART now with dissection flaps
• We advanced the stingray balloon into the mLCx (there were no significant more proximal branches we were worried about losing) and with the wire as true lumen marker were able to stingray back in
• Now we had an antegrade system from LM to Lcx
• We did an IVUS guided PCI from LM into LCx
• Of note she had some VF during the stingray process but this stopped once we got into true lumen and got the vessel open, she left the lab on no pressors, not intubated, and not needing mechanical support

Discussion:
The systematic application of CTO techniques to difficult non-CTO lesions can significantly improve procedural success. Appropriate guide selection, use of microcatheters and wire escalation, and familiarity with bailout strategies are essential to success in such lesions. A structured approach incorporating these advanced techniques can be part of every operator’s skill set.