Meruzhan Saghatelyan, MD, Interventional cardiologistNork Marash Medical Center, Yerevan, Armeniawww.nmmc.am

Heavily calcified ostial RCA CTO PCI in a patient with porcelain

aorta

A 46 y/o man referred to our institution for PCI after diagnostic

CAG because of exertional angina.

Cardiovascular risk factors: hypertension and hyperlipidemia, ex-

smoker.

History of lymphoma and chest radiation therapy.

Coronary angiography revealed porcelain aorta and proximal

occlusion of RCA just after a major RV branch, heavy calcification of

RCA ostium and unclear proximal cap.

Normal sinus rhythm without ECG abnormalities.

Mild to moderate LV hypertrophy and preserved LV contractility

without regional wall motion impairment on transthoracic

echocardiography.

Mild aortic stenosis, mild aortic regurgitation and calcified valve

leaflets, mild mitral regurgitation

Normal renal function.

Laboratory tests were normal.

Coronary circulation was of right dominant type.

Gross calcification of aortic root and both coronary ostia.

CTO of proximal RCA after major RV branch without definite

stump.

Heavy calcification around LM ostium but no significant stenosis

in the left system.

Several septal connections were present.

The first procedure was mainly diagnostic to locate the proximal

cap and to understand the anatomy using 6F JR4 SH guide for

RCA and diagnostic JL3.5 cath. for the left.

Occlusion of proximal RCA seemingly just after origin of RV branch

Seems to be right position but very hard for GAIA II

Tip injection from microcatheter

Trying to locate the proximal cap

Suspected separate origin of main RCA and ostial CTO in this projection

Separate and lower located origin of RCA with downward course and ostial RCA

Short and calcified ostial RCA occlusion

Planning retrograde procedure using one of the septal connections

Guide manipulation and engagement of coronary ostia was very

difficult due to small and totally calcified aortic root. Bifemoral

approach with 7F JL 3.5SH guide catheter for the LM and 6F AR1

guide catheter for the RCA ostium.

Retrograde procedure was planned from the beginning.

We located several not so clear connections to proximal PDA from

2nd septal with tip injection in Corsair.

Sion guidewire crossed the collateral and reached distal vessel.

JL 3.5 guide provided very poor back-up, and to advance Corsair

we tried anchoring. Anchoring in distal LAD did not help. Then we

made anchor ballooning in small atrial branch of LCX that gave

much more support and helped to advance Corsair.

Only JL3.5 7F could be engaged in the LM ostium

Tiny but direct septal connections were located with tip injection in 2nd septal

Passing septal connection with Sion

Advancement of Corsair with the anchoring

Trying to orient Gaia II through RCA ostium

Conquest Pro 9 from retrograde and Conquest Pro 12 from antegrade

Antegrade dilatation with 2.0 balloon for reverse CART

Breaking calcified plaque with 2.5 mm NC balloon for reverse CART

Successful reverse CART with 2.5 mm balloon and Conquest Pro

Predilatation with 1.25mm balloon

Predilatation with 2.0mm balloon

Even a small balloon did not cross over the externalized wire

Antegrade wiring and predilatation with NC balloons

Proximal vessel perforation after predilatation

Promus Premier 2.5 x 32 stent deployement

Deployement of the second 2.5 mm DES

Postdilatation with 3.5 mm noncompliant balloon

Checking the Left system

Final result

Final result

• To advance retrograde Corsair in poor back up conditions

anchor ballooning is useful option. Better support was

achieved with anchoring in atrial branch than in apical

LAD to advance Corsair through septal connection.

• Reverse CART is safer than direct retrograde crossing to

recanalize ostial occlusion to avoid aorto-ostial dissection

or loss of major side branch.

• In very calcified lesions we may need more support than

that with externalized wire alone, to advance balloons

and stents.