Complex CTO PCI by reverse CART technique in a Bangladeshi patient 16 yrs after CABG and its patency after 18 months Follow-up

By: Shams Munwar, MRCP (UK), D. Card (London), FRCP; AHM Waliul Islam, MBBS, PhD., FACC, FSCAI, FAPSIC

Submitted: 04/07/2012

Shams Munwar, MRCP (UK), D. Card (London), FRCP; AHM Waliul Islam, MBBS, PhD., FACC, FSCAI, FAPSIC

Dept of Invasive and Interventional Cardiology, Apollo Hospitals Dhaka.

Apollo Heart Center of Apollo Hospitals Dhaka, Bangladesh

Clinical History
Mr. AZ, a 61 yr old Bangladeshi gentleman, hypertensive, diabetic and Dyslipidemic and known CKD, admitted for CAG of ongoing Angina CCS III-IV. Previously, in the year 1996, he underwent CABG, PTA of Right Renal artery in 2008. CAG revealed native TVD with patent LIMA-LAD, occluded RCA vein graft. Recommended for PCI LMS to LAD and RCA

LM: 80% mid segment plaque (Fig 1) LAD: occluded at ostium LCX: Good caliber vessel. Diffusely diseased. Occluded mid segment. High OM: Good caliber artery. Lengthy 70-80% mid segment plaque. Distal vessels filling from collaterals. RCA: Occluded. PDA filling from Left. LIMA-LAD: Patent. Native LAD has diffuse disease. SVG-RCA: Occluded at Ostium (was patent in 2008) SVG-OM/D1: Picture not attempted (occluded 2008 CAG) Re-look angio (15//6/2011) 18months after PCI, shows patent LM stem, OM and RCA stent.(Fig 11. and Fig 12.)

LCA was engaged with the guiding catheter XB-3.5 (6F). Run through floppy wire was attempted to crossed the lesion of LCX with the help of fine cross micro-channel which was not succeeded. Different wire were attempted to cross through retrograde technique to enter RCA but failed. Finally fielder FC 300 cm wire crossed the lesion of RCA via retrograde route back into RCA and finally through via LFA sheath. (Fig 2 and Fig 3) Tornus used antegradely to dilate and open-up the lesion of RCA. Then, by antegrade approach via RFA, 1.25, 2.0, 2.5 balloon were used to successively dilate the lesion.(Fig. 4). Aorto-ostial RCA lesion was stented with 2.5 x 28 mm Stent (Nobori) at 14 ATM (Fig 5). Proximal RCA was stented with 3 x 14 mm Stent (Nobori) at 14 ATM (Fig 6). Post dilatation was done by 3.0 x 14 mm stent balloon at 18 ATM. Final Cine showed Well dilated RCA with TIMI-III distal run off. (Fig 7.) Then via RFA antegrade approach OM lesion was stented with 2.5 x 28 mm Stent (Nobori) (Fig 8.)and LM lesion was stented with 3.5 x 18 mm stent (Nobori) at 16 ATM (Fig 9 and Fig 10). One year after the PCI, re-look angio showed fully patent stent in the LM, OMX and RCA (Fig 11 and Fig 12.)

Percutaneous Coronary intervention (PCI) to a Chronic Total Occlusion (CTO) lesion is a complex interventional procedure specially in a post CABG patient. Primary success depends on individual interventionist skill and available hard wire support. Long term survival out come depends on the type of stent used and lesion length and risk factor control. Within limited resources available at our facilities, PCI to completely occluded LM-LAD showed stent patency one year after check angio.


Conflict(s) of Interest













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