Angiography was performed via a right femoral access and revealed a patent LIMA to the LAD and SVG for the LCx. The LAD provided collaterals for a small posterior descending artery (PDA). The proximal LCx lesion had not changed from the previous angiogram. The RCA was occluded in the second segment, with severe calcification leading up to the terminal branches. The SVG to the RCA was not visible. A well developed dominant distal RCA was visualised via well developed but very tortuous epicardial collaterals from the LCx ( and , and ). The previously implanted stent in the SVG to marginal branch was widely patent.
The right coronary artery (RCA) prior to treatment. The chronic total occlusion had been documented to be present for 21 years.
Tortuous collaterals from the left circumflex (LCx) artery to the right coronary artery (RCA).
There were no new targets to explain the patient's new symptoms. Given that the inferior wall represented a large ischaemic territory with no evidence of any permanent damage, an attempt to open the RCA CTO was made.
The RCA was cannulated using the left femoral artery using a 7F JR4 SH guide catheter and a Pilot 50 0.014 wire supported by a Finecross microcatheter. An attempt was made for antegrade recanalisation by carving inside the long occluded segment with very stiff wires. A Tornus 0.021 catheter allowed the passage of sequential stiff wires: Confianza Pro 9g 0.014 wire, followed by an 8/12 g and an 8/20 g Confianza wire. This was together with Miracle 0.014 4, 6 and 12 and multiple hydrophilic wires. Despite all this technology, the anterograde approach was unsuccessful with extreme resistance from the occluded segment and no over the wire (OTW) balloon or microcatheter could be passed antegradely into the highly calcified distal RCA.
An attempt was made for a retrograde approach. The diagnostic left catheter was replaced by a 6Fr EBU 4.0 Launcher GC (0.071 inner lumen, Medtronic AVE, Santa Rosa, California, USA) and a series of angioplasty wires were passed in the attempt to negotiate the tortuous epicardial collaterals from the LCx to the RCA in a retrograde manner (). With the support of a Finecross Terumo, a Choice PT wire (Boston Scientific, Natick, Massachusetts, USA) reached the distal RCA vessel. Multiple OTW balloons were used to support the retrograde wire but the tortuousity of the epicardial collateral prevented their advancement to the distal vessel. Therefore a CART technique could not be used. The advancement of a balloon anterogradely for a reverse CART was not appealing because it required a dissection extending beyond the crux, shutting off the PDA.
Retrograde injection via the collaterals to the distal right coronary artery (RCA). A wire is advanced in a retrograde manner to the distal RCA.
A new further attempt was made was using a retrograde approach and STAR technique. The Finecross was advanced through the epicardial collaterals into the distal stump of the occlusion and a Miracle wire was fashioned into a loop or J shape. This was passed into the distal RCA stump and advanced to create a retrograde subintimal dissection. This was enlarged and extended proximally with the use of multiple J-shaped Pilot wires (). An anterograde balloon (2.0 and then 3.0 mm) was then advanced into the third segment of the RCA and inflated along the anterograde subintimal wire. After balloon withdrawal a soft Terumo Runthrough wire could then be easily advanced to the distal RCA. Three stents (2×33 mm Cypher and 1×38 mm Taxus Liberte) were used to cover the entire distal and mid RCA, postdilated to 3.5 and 4.0 mm at high pressure ( and ). An excellent angiographic result was achieved.
Figure 4 A looped/J-shaped miracle wire is passed in a retrograde manner to the occluded distal right coronary artery (RCA) to create a subintimal dissection, which was extended proximally. The antegrade wire is seen in the subintimal space. This allowed antegrade (more ...)
Three stents (two 33 mm Cypher and one 38 mm Taxus Liberte) were used to cover the entire distal and mid right coronary artery (RCA). They were postdilated to 3.5 and 4.0 mm. An excellent angiographic result was observed.
Intravenous heparin was used to maintain an activated clotting time of >250 s. The patient was given aspirin 75 mg once a day and clopidogrel 75 mg once a day. Clopidogrel was continued for 12 months. A total of 320 ml of Visipaque contrast medium was used.