ACI 2018 Best of the Young - CTO PCI using LIMA as Retrograde Conduit - Saqib Ghani

1. Cardiology Case
CTO PCI using LIMA as retrograde conduit
BCIS – ACI 2018
Dr Saqib Ghani
Dr Paul Kelly
Essex CTC, Basildon Hospital

2. Background
• 63 year old male
• Previous CABG in 1998 (LIMA to LAD; VG to D1, RCA and LCX)
• Previous PCI to VG to RCA
• NIDDM, Hypertension, Hypercholesterolemia
• Angina and SOBOE with heart failure (NYHA II-III)
• Medications: Ramipril 2.5mg OD, Bisoprolol 2.5mg OD, Bumetanide 2mg
OD, Metformin 500mg TDS, Nicorandil 30mg BD, ISMN 120mg, Eplerenone
25mg, Atorvastatin 80mg, Aspirin 75mg
• Bloods: Hb 145 g/L, Creat 118 µmol/L (eGFR 54), Total Chol / HDL ratio 6.4

3. Investigations
• ECG: sinus rhythm with narrow QRSd
• ECHO: severe LV systolic impairment with LV EF 25%
• CT Coronary angiogram:
– LAD occluded mid vessel
– LCX non dominant; occluded OM
– RCA occluded
– Patent LIMA to LAD
– All vein grafts (RCA, D1, OM1) occluded
• Invasive coronary angiogram:
– CTO of native RCA (J-CTO score 3) receives retrograde collaterals via LAD septals which are perfused via
LIMA; severely diseased LAD with no targets for PCI
• Cardiac MRI:
– Severely dilated LV cavity with poor systolic function (EF 17%)
– Normal sized RV with moderate impairment
– Partial thickness LV infarction in basal inferolateral wall
– Extensive ischaemia basal to mid inferior and mid to apical anterolateral
– All segments viable with overall ischaemic burden of 15%
• Proceeded with CTO PCI to native RCA

4. Set up coronary angiogram
Known occluded native left coronary

5. Antegrade approach
RRA – 7F AL 1
LFA – 8F IMA
Turnpike 135
microcatheter
Fielder XTA
Pilot 200
Sion black
Gaia 2nd
Confienza pro

6. Antegrade approach
RRA –7F AL 1
LFA – 8F IMA
Turnpike 135
microcatheter
Fielder XTA
Pilot 200
Sion black
Gaia 2nd
Confienza pro
Wire tracking sub
intimally

7. ADR and Stingray

8. Retrograde approach
RRA – 7F AL 1
LFA – 8F IMA
LIMA graft as conduit
Septal collaterals
Caravel microcatheter
Sion black
Ischaemic ECG
Chest pain
Spasm in prox LIMA
Procedure continued
Managed to get to
distal RCA

9. Retrograde approach

10. Reverse CART

11. Final result
IVUS guided stenting resulted in RCA being treated with 4 x DES (Xience 2.25 x 12, Xience 2.5 x 48, Xience 3.0 x 38 and
Xience 3.0 x 38); post dilated with 3.0 NC; good angiographic result. The LIMA graft was intact with no spasm at the end.

12. Discussion
• An interesting and challenging case of CTO PCI using LIMA
graft for retrograde approach
• LIMA graft is prone to spasm with used as coduit for PCI
• CTO PCI using LIMA graft as retrograde conduit was
performed in 2% (20 out of 990) of patients in US registry of
18 centres, with technical and procedural success rate of 70%
and no significant difference in major in-hospital complication
– Tajti P et al. J Invasive Cardiol 2017; Nov 15. pii: JIC20171115-1
• Our patient was discharged from hospital following day
without any complications; remains well 6 months post PCI