Successful recanalization of a blind stumpless aorto-ostial left main chronic total occlusion

Abstract

A49year-oldwomanwasreferredforincreasingdyspnoeaonexer-tion.Shehadsevereobesityanduncontrolledtype-2diabetesandwasacurrent smoker. Transthoracic echocardiogram was performed, show-ingseveresystolicdysfunction(EF0.30),moderatemitralregurgitation,elevated left ventricular filling pressures and moderate pulmonaryhypertension.Thus,coronaryangiogramwasindicated.Rightdominantcoronary artery showed no significant lesions and filled retrogradelyboth left anterior descending and circumflex arteries up to the leftmain. Several diagnostic catheters failed to intubate left main artery.Aortography revealed total left main occlusion.The patient was referred for surgery and a left internal mammaryartery (LIMA) bypass graft to left anterior descending artery (LAD)was performed. Patient experienced severe heart failure requiringhigh doses of inotrope and loop diuretics and was discharged 3 weeksafter admission. Unfortunately, 5-days after discharge the patient wasadmitted with severe biventricular failure. A second coronary angio-gram confirmed LIMA occlusion. We considered in a multidisciplinarymeeting to attempt the LM occlusion percutaneously with retrogradeinjections via right coronary artery.We faced the first problem of the absence of both radial pulses (longIntensiveCareadmission)andtheabsenceofleftfemoralpulse(severeperipheral disease). Thus, we made a “blind” antegrade approach via 6Fright femoral approach. A Judkins-left 4 6-Fr guiding catheter was placedin the left aortic sinus and we patiently advanced a Fielder XT guidewire(Ashahi Intecc Co., Japan) where we “guessed” the LM might be.