Live Case Demonstration
In order to illustrate the points discussed, a live case was presented from the Institut Cardiovasculaire Paris Sud, Massy, France. The patient was a 56-year-old man with hypertension and hyperlipidemia, and he was an ex-smoker, but had an active lifestyle. The patient had a history of obstructive sleep apnoea and ischaemic heart disease with inferior ST elevation in 2007, when he underwent implantation of a bare-metal stent (BMS) into the left circumflex artery (LCX). In 2012 he had a negative MRI stress test. He presented with 3 months of dyspnoea and a positive MRI stress test in April 2015. At this time his renal function was normal. An ECG showed evidence of the previous infarct. An echocardiogram showed focal hyperkinesis with normal pulmonary pressures and there was a positive MRI for ischemia in the atrial septal regions; the injection fraction was normal in the two-chamber view; and focal anteroseptal and apical ischaemia were detected in 4 of 17 segments. A delayed perfusion scan showed evidence of the previous infarct. The cranial view on angiogram showed proximal left anterior-descending artery (LAD) occlusion with a tapered proximal cap. The right coronary artery (RCA) also showed proximal stenosis.
A biradial antegrade approach was used from the left radial artery to the RCA, with the aim of minimising the risk of bleeding complications. The occlusion was a CTO of approximately 10 mm with a J-CTO score of 0 or 1. An antegrade microcatheter approach was taken to penetrate the proximal cap using soft wire, thus minimising the use of a contrast agent. A double injection was used. Little ischaemia was evident but a proximal LAD occlusion was seen. The Gaia guidewire was rotated rather than pushed into the cap. The proximal section was relatively easy to cross but the distal section was more difficult. The wire was withdrawn and re-entry attempted but it was not possible to cross the lesion with a microcatheter. To stabilise the catheter, trapping with a balloon was considered the safest approach. At the second attempt, the wire still did not move freely but managed to cross the occlusion. However, difficulty was encountered in crossing the occlusion with a balloon. An anchoring technique was then used to support the guide. The guidewire was changed and a subsequent predilation with a 2.0 balloon proved easier. However, the lesion was so calcified that the predilation was not fully successful, therefore a 2.5 balloon was used, up to 20 atmospheres. A single Coracto stent was implanted and IVUS confirmed that the outflow was good. DAPT was planned for a maximum 6 months. If the patient tolerates DAPT and is doing well, there is no need to stop early.
The publication of this article was supported by Alvimedica.