Abstract
Recanalization of coronary artery chronic total occlusions is a rapidly developing domain of percutaneous coronary interventions requiring considerable operator expertise. Tackling any aorto-ostial lesion with previously implanted stent that protrudes into aorta presents anatomical and technical challenge significantly reducing procedure success rates and is an obstacle when considering antegrade approach in chronic total occlusion cases. We present an illustrative case report of successful antegrade recanalization of chronic total aorto-ostial in-stent occlusion of right coronary artery with previously implanted protruding stent.
Highlights
Chronic Total Occlusion (CTO) recanalization represents the summit of advance in contemporary Percutaneous Coronary Intervention (PCI) techniques and operator expertise
Four months later due to persisting symptoms despite optimal medical treatment the patient has been referred to high-volume interventional cardiologist with special interest in CTO PCI for repeated right coronary artery (RCA) recanalization attempt
Suboptimal AL 0.75 guiding catheter position above the ostium of RCA (Figure 1A) with contrast injection has showed a small blunt aorto-ostial occlusion stump with no antegrade flow (TIMI 0) and protrusion of previously implanted RCA stent of approximately 4 millimetres into the aorta explaining the difficulty in selective ostial RCA intubation (Figure 1B)
Summary
Chronic Total Occlusion (CTO) recanalization represents the summit of advance in contemporary Percutaneous Coronary Intervention (PCI) techniques and operator expertise. Aorto-ostial lesions with previously implanted stents protruding into aorta are technically challenging even in non-CTO cases They are known to significantly reduce procedure success rates and present a considerable drawback from attempting antegrade approach in CTO PCI. Protrusion of aorto-ostial stents accounts for suboptimal or difficult guiding catheter engagement, lack of support and wire control, difficulties in delivery of micro catheters, balloons and stent systems [1] This case report illustrates successful antegrade recanalization of chronic total aorto-ostial in-stent occlusion of the right coronary artery (RCA) with previously implanted protruding stent. Suboptimal AL 0.75 guiding catheter position above the ostium of RCA (Figure 1A) with contrast injection has showed a small blunt aorto-ostial occlusion stump with no antegrade flow (TIMI 0) and protrusion of previously implanted RCA stent of approximately 4 millimetres into the aorta explaining the difficulty in selective ostial RCA intubation (Figure 1B). The patient continued on regular medical treatment with dual antiplatelet therapy and anginal symptoms resolved
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