Case 260: Manual of CTO PCI - Retrograde through LIMA

A patient was referred for recanalization of an LAD CTO. She had prior CABG with patent LIMA-2nd Diagonal but there was a severe lesion proximal to the LIMA distal anastomosis. The CTO proximal cap was located at the origin of the 1st diagonal branch with the distal vessel reconstituting at the origin of the 2nd diagonal that was filling via the LIMA.
Antegrade wiring with a Gaia Next 3 wire resulted in extraplaque crossing. Parallel wire failed. A Sion black wire was advanced retrogradely to the LAD via the LIMA through a Caravel microcatheter. The patient tolerated this maneuver well without hemodynamic compromise, chest discomfort or ischemic changes. However, the Caravel could not be advanced retrogradely towards the LAD - it was prolapsing distally in the 2nd diagonal.
Using the retrograde wire as marker a Stingray balloon was advanced antegradely distal to the origin of the 2nd diagonal branch, followed by successful re-entry using the stick and swap technique. The origin of the 2nd diagonal was compromised but this did not have any clinical sequelae as the 2nd diagonal was filling via the LIMA.

[@shangz0216]

Thanks for the excellent case presentation.

[@maen787]

Great case, thank you for sharing :)

[@nanoevolution1]

Would the streamlined double lumen catheter have had a chance to pass the wire retrogradely in this case?