How to advance the Corsair throughoutl h la narrow septal channel

Hidetsugu Sakai, MD. , PhD.

Catheterization Laboratory Department of Cardiovascular MedicineCatheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

Case66 year-old gentlemanDiagnosis : OMI (ant), post-PCIDiagnosis : OMI (ant), post PCIHistory

He was suffered from acute anterior myocardial infarctionHe was suffered from acute anterior myocardial infarction about 1 year before and received stent (BMS 3.0-16mm) placement onto mid-LAD TIMI-0 lesion. But he again p gcomplained of angina and CT angiography showed instent total occlusion 8 months after the initial procedure.

EchocardiographyReduced anterior wall motion, LVEF 52%N l l diNo valvular disease

Catheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

1st PCILeft CAG showed total occlusion

of middle segment of LAD.g

We placed a bare metal stentafter aspiration and predilatationwith IVUS-guidance.

Final CAG showed TIMI-3 flow restorationof infarcted vessel.

Catheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

2nd PCILeft CAG showed instent total occlusion

of middle segment of LAD.g

We started the procedure transradiallywith a 6Fr guiding catheterand manipulated a neo’s Conquest-Pro.

But it went wrong into the subintimal space

Next, we performed the parallel wiret h i i ’ C t P 12

at the distal edge of the stent.

technique using a neo’s Conquest-Pro 12.

Neither of the guidewires failedto cross lesion

Catheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

to cross lesion.

2nd PCIThen, we advanced a 6Fr retrograde system

via right femoral artery.

We successfully advanced a neo’s Fielder-XT throughout a septal channelas far as the distal edge of the lesionas far as the distal edge of the lesion.

But a Corsair microcatheter could not beadvanced within the septal channeladvanced within the septal channelbecause of little back-up support.

Catheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

2nd PCIIn order to increase the support of guidewire,

we intentionally advanced itt d i l LADtoward apical LAD.

We could advance Corsair microcatheterby slowly rotating it clockwiseby slowly rotating it clockwise.

Finally, both the Corsair and guidewirecould be advanced as far as the lesioncould be advanced as far as the lesion.

Catheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

2nd PCIWe advanced a neo’s Conquest-Pro retrogradely into instent lumen.

Next, we performed reverse CARTusing a 2.5-20mm antegrade balloon.

Retrograde neo’s Fielder-FC went intothe antegrade guiding catheter.

We performed the trapping technique.

We established guidewire externalizationwith a RG-3 guidewire.

Catheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

2nd PCIWe performed predilatation

using the previous 2.5-20mm balloon.

Next, we performed IVUS …..

Three everolimus-eluting stents were placed.g p

Final angiography after postdilatationshowed that the lesion was well dilatedwithout any complications.

Catheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

ConclusionIt is well known that bi-directional approach using intra-coronary collateral channels is of much effect to treat CTO.There are controversies about puncture site and guiding catheter size.It is clear that 6Fr retrograde systems provide less back-up force than 7Fr or 8Fr systems.In some cases, retrograde microcatheters cannot cross septal channels and septal dilatation using 1.25mm balloon is effective in such situationsis effective in such situations.In this case, we intentionally advanced guidewire in opposite direction and achieved good back-up force

Catheterization Laboratory, Department of Cardiovascular MedicineKushiro City General Hospital, Kushiro, Japan

direction and achieved good back-up force.