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1、Percutaneous coronary intervention of a left anterior descending chronic total occlusion using an epicardial collateral retrograde approach,Dr Patricia HT HonDr David CK Hu,CTO-LAD retrograde approach,59 yo male exertional angina March 07Risk factors:hypertension,hyperlipidaemia,new onset Type 2 DM
2、and smoking occasionally,CTO-LAD retrograde approach,CTA coronary angiogram:severe and extensive disease shown in RCA and LADLV function satisfactory on echocardiogram,CTO-LAD retrograde approach,Diagnostic coronary angiogram March 07:CTO mid LAD,severe proximal disease,good collateral retrograde fi
3、lling from RCASevere disease distal LCX,sub-total occlusion(TIMI-2)90%lesion mid RCA and 50%disease PDA,CTO-LAD retrograde approach,Management plan:PCI to RCA+surgical stand-by(high risk)Staged revascularisation to CTO-LAD and LCX either surgically or by PCI,CTO-LAD retrograde approach,March07:mid R
4、CA stented successfully(Xience V 3.5mm x 23mm),CTO-LAD retrograde approach,Exercise nuclear perfusion scan 3 weeks after stenting of mid RCA:No significant ischaemia in LAD territory.Frequent PACs noted during exercise Option of revascularization of LCX and CTO-LAD or conservative therapy:patient ch
5、ose latter,CTO-LAD retrograde approach,Enjoyed long periods of exercising vigorously without anginal symptomsNov 07:recurrence of chest discomfort and developed paroxysmal AFNew ST depression on exercise treadmill,CTO-LAD retrograde approach,Restudy coronary angiogram Nov 07:Patent RCA stentNew lesi
6、on 80%proximal RCA LAD and LCX disease as before,CTO-LAD retrograde approach,Adhoc stenting to new lesion proximal RCA(Endeavor 3.5mm x 18mm)Sub-total occlusion LCX stented(Endeavor 2.25mm x 14mm)Attempted but failed to re-open CTO-LAD in antegrade approach,CTO-LAD retrograde approach,Options:PCI to
7、 CTO-LAD using retrograde approachvsCABG using LIMA to LAD(dual anti-platelet therapy),CTO-LAD retrograde approach,Jan08:PCI to CTO-LAD using RCA-epicardial collateral retrograde approach,CTO-LAD retrograde approach,Bilateral femoral artery puncture6F XB-LAD 3.75 catheter LAD7F AL-1 catheter to RCA,
8、CTO-LAD retrograde approach,Microcatheter(Ichiban-Yari,Japan)Guidewire(Fielder,Asahi Intecc,Japan)Successfully crossed the CTO-LAD through RCA collateralPositioned in proximal LAD,CTO-LAD retrograde approach,Guidewire dockedMultiple balloon dilatations(Lacross)from distal lumen to proximal lumenAntegrade Fielder wire passed into distal LAD3 stents(Endeavor 3 mm x 18mm,2.75 mm x 24mm,2.5 mm x 30mm)deployed successfully,CTO-LAD retrograde approach,Primary stenting(Xience V 2.5 mm x 18mm)to PDA peformed,
