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Impossible to Cross the Lesion With The Balloon
T. Lefèvre and P. O’Kane
Institut Cardiovasculaire Paris Sud
Massy, France
Case Summary
Demographics / CVRFs / Clinical presentation
Male 70 years oldHeight 182 cm, Weight 61 Kg, BMI 18.4DyslipidemiaPrevious smokerHBP
Pace maker in 2006CRT-D in 2011
Admitted for pulmonary oedema
Case Summary
EKG / Non-invasive Testing
EKG: Pace Maker
Echocardiographie: Diffuse hypokinesia, EF 30%
MRI: Anterior MI, viability 75%
Angiography / imaging
Total occlusion of the mid LAD
Angiography / imaging
Intermediate lesion of distal RCA (FFR 0.85)Collateral from RCA to LAD via septal channel
Summary
70 years old malePulmonary oedemaAnterior viabilityJ-CTO score 3
1. Puncture with a stiff / mod stiff wire
2. Navigate the mini-channel with a polymeric wire
3. Dissection and reentry
4. Use imaging as a guidance (IVUS, MSCT)
Which would be your initial approach?
Initial Approach
PCI for LAD CTO with contralateral injection
Failure to cross with Finecross, 1.25 mm balloon and Tornus Despite Mother and child technique
1. Retrograde approach
2. Dissection and reentry
3. Dilatation of the subintimal space
4. Laser
Which would be your Next step approach?
Step 1: Antegrade approach and Laser.
Step 2: If failure, consider retrograde approach in the same setting
Case Strategy
Case Summary
Duration of the procedure: 3 hours and 42 min
Fluoroscopy time: 118 min
Xray exposure: 6.2 Gray
Total amount of contrast: 410 ml
In-hospital outcome: No event
6-month outcome: EF increase from 30 to 47%
Key learning points
Learning point 1: Laser for undilatable lesions
Learning point 2: Mother and child technique
Learning point 3: We can use the retrograde channel for antegrade crossing
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