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What do you do when a calcified RCA CTO case stalls, your equipment will not deliver, and conventional reverse CART strategy becomes difficult?
In this MurmurMD discussion, Dr. Chris Brown and Dr. Eric Rothstein review a challenging CTO case involving a 57-year-old patient with five years of angina, a large ischemic RCA territory, prior LAD treatment without symptom improvement, and a heavily calcified RCA CTO.
The case evolves through several classic CTO decision points: upfront ADR consideration, side-branch anchoring, architectural knuckle formation, intralesional ambiguity, retrograde septal crossing, difficulty joining tissue planes, and ultimately the use of intravascular lithotripsy to modify calcified subintimal/extraplaque space and facilitate reverse CART.
KEY TOPICS
• RCA CTO with long-standing angina and ischemia
• Hybrid CTO strategy and switching approaches mid-case
• Side-branch anchor technique for guide support
• Large architectural knuckle vs small knuckle strategy
• Intralesional ambiguity and how to define the vessel course
• Retrograde septal crossing strategy
• Why guide extension delivery can fail in calcified CTOs
• IVL use in the subintimal/extraplaque space
• Shockwave to facilitate reverse CART
• Trapping, microcatheter delivery, and externalization
• IVUS interpretation after CTO crossing
• Conservative sizing in the subintimal space
• Why IVL may be preferable to atherectomy in this setting
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Chapters:
00:00 – Key concept: microcatheter delivery and externalization
00:22 – Case introduction
00:44 – Patient presentation: 57-year-old with five years of angina
01:45 – RCA CTO anatomy, J-CTO score, and initial strategy
02:46 – Failed knuckle formation and need for more guide support
03:28 – Side-branch anchor technique in the conus
04:44 – Large architectural knuckle strategy
05:54 – Intralesional ambiguity and CTO decision-making
06:54 – Options: bigger knuckle, BASE, Carlino, or retrograde definition
07:55 – Switching to retrograde strategy
08:57 – Septal surfing and retrograde crossing
11:00 – Retrograde support, guide extension limits, and plaque modification
12:16 – Balloons fail to expand in the subintimal space
14:00 – Shockwave IVL to modify calcified CTO architecture
15:00 – Anchor technique to deliver larger equipment
15:39 – Retrograde wire choice for reverse CART
17:07 – Moving the reverse CART strategy proximally
19:01 – Wiring the guide vs snaring
19:50 – Balloon trapping to deliver the microcatheter
20:50 – Externalization with R350 or RG3
21:13 – IVUS: true lumen, subintimal space, and hematoma
22:10 – Ballooning, stent sizing, and conservative expansion
22:49 – Final IVUS and result
23:27 – Why IVL may be safer than atherectomy in the extraplaque space
24:23 – Closing thoughts and key learning points
#CTO #ComplexPCI #IVL #IntravascularLithotripsy #ShockwaveIVL #ReverseCART #RCACTO #CoronaryCalcium #InterventionalCardiology #CathLab #MurmurMD
