Case 187: Manual of CTO PCI - The safety wire

A patient was referred for PCI of an LAD CTO. The CTO had a well-defined tapered proximal cap, length of approximately 20 mm, diffusely diseased distal vessel with a bifurcation at the distal cap that was filling via septal collaterals. Antegrade wiring failed and a retrograde crossing attempt was performed via the septal collaterals from the PDA. The patient had sudden onset hypotension and ST elevation. Angiography showed RCA dissection. Two DES were quickly implanted in the RCA, restoring antegrade flow and resulting in resolution of the hypotension and the ST elevation.
Repeat antegrade wiring attempts with a Gladius Mongo wire resulted in extraplaque crossing. The Corsair microcatheter was advanced to the mid RCA after balloon angioplasty with a Sapphire 1.0 mm balloon, followed by exchange of the Mongo wire for a Miracle 6 wire. The goal was to use the Miracle 6 to deliver a Stingray balloon for reentry, but the Miracle was advancing easily and contralateral injection showed that it was in the distal true lumen.
A wire was placed in a large diagonal branch using a Sasuke dual lumen microcatheter, followed by stenting of the LAD, rewiring of the diagonal with the Sasuke microcatheter and kissing balloon inflation. A nice final result was achieved and the patient had an uneventful recovery.

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