S206 J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 9 , N O . 1 6 , S U P P L S , 2 0 1 7

Case Summary. Antegrade procedure for LCX-ostium CTO lesionwithout stump is possible.Adequate adjustment of angulated view is the key of successful PCI

of ostium CTO lesion with unusual anatomy.Ostial and ISR CTO lesions are not always hard and can try inter-

mediate wire first.Broken-tip wire technique is a good method to cross very tortus

collateral channel, but the problem is difficult to cross micro-catheter.

TCTAP C-117

CTO-PCI to RCA with Severe Tortuosity and Lotus Root-likeAppearance.

Masaki Tanabe11Kyoto Okamoto Memorial Hospital, Japan

[CLINICAL INFORMATION]Patient initials or identifier number. YTRelevant clinical history and physical exam. A 71 years-old male patientsuffered from chest oppression on effort and he admitted to ourcatheterization to undertake re-attempted PCI. He had a chronic totalocclusion (CTO) at the mid to distal right coronary with lotus root-likeappearance and severe tortuosity with two big curves. He had beenundertaken coronary intervention to this RCA-CTO in 2008 in ourcardiac catheterization laboratory, but without success due to failureof passing guide wires.Relevant test results prior to catheterization. According to his medicalreport, his onset of inferior myocardial infarction was in 1994. Coro-nary angiography completely occluded at the mid RCA in those days.In 1995, The RCA had a specific lesion with lotus root-like appearanceat the mid portion in his restudy angiography.Relevant catheterization findings. RCA had a CTO at mid to distal sitewith lotus root like appearance.Moreover, the morphology of RCA was significantly tortuous having

two acute curves.The distal branch of the PL branch of RCA had occluded completely,

which supplied by contra lateral collateral’s. However,there was nointerventional collateral.The LCA had no re stenosis at the LCX which had been underwent

PCI at the ostial LCX, and the LAD which had been underwent PCI’s atthe proximal to mid portion.

[INTERVENTIONAL MANAGEMENT]Procedural step. The PCI to the mid RCA-CTO started by right transfemoral approach after guide catheters insertion using the 8Fr JR4with side holes to the RCA ostium. Regarding retrograde approach, itwas not considered because of no interventional collateral. Firstly,antegrade wiring started using the Gaia 1st with the Corsair microcatheter support. It managed to penetrate into the CTO entry but wasnot able to advance just after the CTO entry. Therefore, the Gaia 1stexchanged to the Gaia 2nd. The Gaia 2nd managed to cross over the 1stacute curve into the CTO segment, however, it was not able toadvance anymore.

J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 9 , N O . 1 6 , S U P P L S , 2 0 1 7 S207

Consequently, wire escalation of Miracle brothers (Miracle 6g and12g) performed, but, did not work. These wires was not able to followthe direction of the 2nd curve but advanced in a linear manner.Therefore, re-attempting antegrade wiring using the Gaia 2nd wasperformed for negotiation the 2nd curve of into the CTO segment.Eventually, wire manipulation with the Gaia 2nd was successful innegotiating to the 2nd curve of into the CTO segment. And then, itadvanced into the distal CTO segment after successful passingthrough the 2nd curve of the CTO segment, and it was successful inpassing through all the CTO segment antegradely. Two new genera-tion SESs were implanted over the CTO segment as a final procedure.The final angiography had a satisfactory image because of successful

interventional revascularization of the RCA.Case Summary. Wire selection and wire manipulation of the Gaia 2ndworked strategically, in case of the performance of antegrade the RCA-CTO PCI with lotus root like appearance and severe tortuosity havingtwo acute curves for successful in interventional revascularization.

TCTAP C-118

Successful PCI for Stumpless RCA Chronic Total Occlusion withIVUS-guidance

KangUn Choi,1 Jung-Hee Lee11Yeungnam University Medical Center, Korea (Republic of)

[CLINICAL INFORMATION]Patient initials or identifier number. 13369029Relevant clinical history and physical exam. A 67-year old male patientvisited our hospital because of exertional angina. He had risk factorsof hypertension, old cerebrovascular accident, peripheral arterialocclusive disease and ex-smoker (30 pack-year). He was alreadydiagnosed with stable angina and proximal RCA chronic total occlu-sion (CTO) 7 years ago. He maintained an optimal medical treatment,but his symptom not improved. Therefore, we decided to performpercutaneous coronary intervention for this CTO segment.Relevant test results prior to catheterization. Echocardiography showedmild hypokinesia on inferoseptal and inferior wall with preserved leftventricular systolic function (EF 52%).Relevant catheterization findings. By using femoral approach with 7-Frsheath, angiography revealed chronic total occlusion at proximal RCA(pRCA)with bridging collateral flow. Proximal stump of CTO segmentwas not clearly visible. Furthermore, collateral from left coronaryartery was poorly developed.[INTERVENTIONAL MANAGEMENT]Procedural step. Because collateral flow from left coronary was poorlydeveloped, we had to perform CTO intervention in antegradeapproach. To overcome, stump less CTO, we decided IVUS-guidedwiring. At first, we introduced the floppy guide wire(RunthroughTM,Terumo, Japan) to proximal side branch for IVUS evaluation. IVUSimaging clearly revealed proximal part of occluding segments. Then,we tried to penetrate with Fielder XT-A under micro catheter (Fine-crossTM, Terumo, Japan), and the guide-wire easily slip to the prox-imal cap of CTO segment. However, it could not pass through thedistal CTO segment. We changed guide wire to a stiff guide-wire (GAIAsecond, ASAHI,Japan). The guide wire successfully passed into targetlesion. Then, sequential balloon angioplasty was performed, and IVUSimaging showed that RCA vessel diameter about 3.0 mm. Weimplanted 2.75 x 28 mm drug-eluting stent (DES) (Synergy,Boston),3.0 x 32 mm and 3.5 x 20 mm DES at from distal to proximal RCA. Finalangiogram revealed showed TIMI 3 flow with preservation of all sidebranches. After procedure, his symptom was much more improvedand discharged without any complications.