acaseofctoa case of cto withguidewith guide-wire stuck in...

A case of CTOA case of CTOA case of CTO A case of CTO with guidewith guide--wirewire stuckstuckwith guidewith guide wire wire stuck stuck

inin retrograde approachretrograde approachin in retrograde approachretrograde approachShingo HosogiT Nishimoto Y Yoshimura Y Fukuoka H MatsumiT. Nishimoto, Y. Yoshimura, Y. Fukuoka, H. Matsumi, T. Miyaji, S. Sahara, Y. Ohara, M. Nishimoto,K YamamotoK. Yamamoto

Kochi Health Sciences Centerf C

Kochi Health Sciences Center

Department of Cardiovascular medicine

A A case:case: 88 88 y.oy.o. male. male1996 AMI (no CAG/PCI)1996, AMI (no CAG/PCI)18 Sep. 2012, effort AP19 Sep. 2012, CAG

RCA#1 CTORCA#1 CTO, LCX#11, #13 75% stenosis.

C i k f tCoronary risk factorSM(previous), HT+, HL+, DM-, FH+SM(previous), HT , HL , DM , FH


ECG & Chest XECG & Chest X--ray & UCGray & UCG

CX

LC


CAGCAG

RCA#1 CTO, LCX11 75%, LCX13 90%, LAD7 50%


, , ,Collateral vessel from LAD and LCX to RCA

Target LesionTarget Lesion

RCA#1 CTO,


,Collateral vessel from LAD and LCX to RCA

Plain cardiac CTPlain cardiac CT

Thick calcification in RCA#2


Thick calcification in RCA#2Refrain from contrast use due to CKD (Cr1.6)

PCI systemPCI system 7F Long sheath (40cm) g ( )

from Bilateral Femoral Artery G idi C th t (GC) Guiding Catheter (GC)：

AL1ST 7F(Brite-tip) for RCA( p)SL4.0 7F(Launcher) for LAD

Guidewire (GW) from antegrade approach Guidewire (GW) from antegrade approachX-treme XTA

Micro-catheter (MC) from antegrade approachCorsair135cmCorsair135cm


Ante. approachAnte. approach■Antegrade approachMC：Corsair135cmMC：Corsair135cmGW：X-tremeXTA→Gaia1st→Gaia2nd→Conquest Pro→ Not pass due to thick calcification in RCA#2→ Not pass due to thick calcification in RCA#2


Change to Retro.Change to Retro.■MC：Corsair150cm■GW：Sion


Retro. approachRetro. approach MC：Corsair150cm GW：Sion → Ultimate3 → Gaia2nd

→Successfully pass


Retro. approachRetro. approach Gaia2nd was successfully inserted and anchored by

balloon in antegrade GC. g However, Corsair150cm could not pass at the thick

calcification in RCA#2.


RetroRetro GWGW injuredinjuredjj①Corsair150cm never advanced over the thick calc. ②Slit was appeared in the retro.GW, Gaia 2nd.② pp ,


Aft th d t d id i d dRetro GW did not snap, but stuckRetro GW did not snap, but stuck

■After the procedure, retrograde guide-wire was damaged with lump of coil, and could not move except between thick calc and tip of Corsairthick calc. and tip of Corsair.

Gaia2nd

thick calc.

damaged GW with lump of coil

C i 150


Corsair150cm

What would you do ?What would you do ?yy

Gaia2nd ①Pullout the GW and MC retrogradely→Going back to square one

Would damage the collateral vessel

②P ll h GW d MC d lSevere calc. ②Pullout the GW and MC antegradelyusing snare catheter

→Would damage the collateral vesseld d GW ith l f il →Would damage the collateral vesselCould finish the PCI successfully

damaged GW with lump of coil

Corsair


GW pulling out by snareGW pulling out by snareSnare：Amplatz Gooseneck snare

g yg y

■R d GW■Retrograde GW was forcibly pulled out via y pantegrate GC by using snare cathetersnare catheter. ■Retrograde MC was inserted into AntegradeGC.GC.


RendezvousRendezvous methodmethod■After Retro MC was inserted into Ante.GC ･･･

In general, catheter is always advanced at outside of the curve in GC. RetroMC and ante MC were inserted to theRetroMC and ante MC were inserted to the same strong curve point of MC, then anteGWcould be easily inserted from ante MC into retro MC

AnteGW

retro MC.

AnteMC

AnteGC

Kochi Health Sciences CenterRetroMC

Balloon and StentBalloon and Stent■GW was successfully inserted antegradelyusing Rendezvous methodusing Rendezvous method

■Pre dilatationTazuna1.5X15mmPowered L 2 X1Lacrosse2.5X15mm■IVUS■StentPromusElement2.5*38PromusElement3.0*20■Post dilatationPost dilatationTazuna2.25X15mmHiryu3 0X15mm


Hiryu3.0X15mm

CAG after postCAG after post--dilatationdilatation■hemorrhage at distal part of the collateral vessel. (due to forcibly pulling out of retro GW)■BP40-60mmHgBP40 60mmHg


Hemorrhage from collate.Hemorrhage from collate.■hemorrhage at distal part of the collateral vessel. (due to forcibly pulling out of retro GW)■BP40-60mmHgg■Balloon(1.5mm) dilatation with low pressure■Heparin reverseHeparin reverse■NoA■Super-selective infusion of micro-tissuetissue

Contrast pool was still remained in basal-inferoseptal myocardium andbasal inferoseptal myocardium and inside of epicardium.However, Cardiac US showed no PE,

and vital state became stable.

Finished PCI successfully.


Final Final Lt.CAGLt.CAG


Final Final Rt.CAGRt.CAG


CAG at CAG at 33--m f/um f/u


Damaged GW, GaiaDamaged GW, Gaia22nd nd (in vitro)(in vitro)Total Length 1900mm

Slip Coat Coating Length 400mm

Coil Length 150mm 0 014inch PTFE coatg 0.014inch PTFE coat

First：0.010inchSecond：0.011inch

damaged GW with loose coil(in vitro)


(in vitro)

SummarySummaryWe experienced a CTO case with retrograde GW,

Gaia, trouble.Gaia is a new GW with a good torquability, thus is Gaia is a new GW with a good torquability, thus is

becoming a popular GW especially in CTO PCI in JapanJapan.However, the outer coil of Gaia could be damaged

and lead to vessel injury in the tough situation suchand lead to vessel injury in the tough situation such as CTO and retrograde approach.Thus, we should know about this phenomenon of

Gaia especially in CTO PCI.p y


acaseofctoa case of cto withguidewith guide-wire stuck in...

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