Complex Retrograde CTO-PCI With Laser Atherectomy and a Novel Tip-In Technique Into a Guide Catheter Extension.

OBJECTIVE

We present a challenging case of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using laser atherectomy and a novel tip-in microcatheter technique in conjunction with a TrapLiner guide extension catheter (Teleflex).

CASE SUMMARY: Left heart catheterization showed multivessel disease. The patient was turned down for surgical intervention and hence underwent PCI to the mid right coronary artery and staged retrograde CTO-PCI of the proximal left anterior descending artery. The CTO-PCI procedure was performed using a retrograde approach but because the microcatheter advanced over the externalized wire could not be used to wire into the ongoing left anterior descending artery, we explored innovative ideas. The distal small septal channel was crossed using a tip-in technique wherein the distal tip of an antegrade microcatheter was trapped in a TrapLiner catheter and intubated with the retrograde guidewire. The antegrade microcatheter was advanced over the retrograde wire, and laser atherectomy was performed followed by PCI, with excellent results.

CONCLUSIONS

Using advanced techniques such as tip-in maneuvers with equipment such as the TrapLiner can make the difference in complex CTO-PCI cases that otherwise would fail.