Successful Retrograde Approach Of RCA

CTO Lesion With Anomalous Origin Of

RCA Ostium

MD, PhD. Sung-Ho, Her

Department of Cardiology, Daejeon St. Mary’s Hospital

The Catholic University of Korea, Seoul, Korea

C/C : exertional chest pain

P/I : A 49 year-old male with a history of hypertension and

end-stage renal disease received hemodialysis. He was

admitted from OPD clinic for worsening exertional chest pain.

12 months prior, angiography; showed chronic total occlusion of proximal LAD visualized collateral flow from

LCX and no engaged and no visualized RCA ostium by aortogram.

12 months prior, angiography; no engaged and no visualized RCA ostium by aortogram.

12 months prior, PCI

:At that time, performed and stenting by 3.5*24 mm + 3.0*24 mm promus element

in the proximal to middle LAD by antegrade approach.

12 months prior, PCI

; After PCI, left coronary angiography demonstrated grade 3 collateral flow from

LAD via septal branch, filling in a retrograde manner, the distal RCA.

PCI ; Retrograde approach

We thought of RCA ostium CTO lesion without stump

and therefore, decided retrograde approach.

We inserted 7Fr sheath at both femoral artery. EBU7-

3.5 guiding catheter engage at LM Os and 7Fr

Judkins right catheter inserted at ascending aorta.

Field FC 300 cm guidewire was used to bypass the lesion through use of the collaterals, supported by Corsair catheter. Field FC wire was not passed at mRCA and then guidewire changed (=> miracle3 => conquest pro12).

Finally, the conquest pro12 guidewire passed to aortic arch, but corsair catheter was not passed at pRCA CTO lesion. Field FC 300 cm wire changed. Field FC wire was snared and pulled back with corsair catheter into 7Fr Judkinsright catheter and Judkins right guding catheter was deep engaged.. So Field FC wire was become externalization.

The long lesion was dilated by 1.25*20 mm ryujin balloon and a 2.5*15 mm

ryujin balloon, respectively with several times antegradely.

IVUS; Runthrough wire was rewired to RCA

antegradely and IVUS was done.

Distal to middle RCA Proximal RCA to Ostium

Three stents, 3.5*38 mm endeavor integrity, 3.5*28 mm Nobori,

3.5*24 mm Nobori, were implanted in the distal-, mid- and proximal RCA with

overlapping

Final angiogram

Final angiogram and coronary CT

; We mistaked intact RCA ostium for RCA ostium CTO lesion.

; RCA ostium was originated from right coronary cusp, anomalously and superiorly

Conclusion

• We successfully procedured RCA CTO lesion with anomalous origin of RCA ostium by retrograde approach.

• If possible, check the coronary CT for CTO lesion before PCI.