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