Journal of Cardiology and Heart Failure

ABSTRACT

Background

Percutaneous Coronary Intervention (PCI) for Chronic Total Occlusions (CTO) is technically demanding. Even lesions with favorable angiographic characteristics may behave unpredictably and require strategic adaptation.

Case Summary

A 55-year-old male with Canadian Cardiovascular Society (CCS) class II–III angina was found to have a short, tapered chronic total occlusion of the mid-right coronary artery (RCA) at the level of the right ventricular (RV) branch. Initial antegrade wiring with an Asahi XTA wire crossed the occlusion but entered a side branch, resulting in extensive subintimal dissection. Subsequent antegrade dissection re-entry (ADR) and parallel-wire attempts failed and were complicated by distal tip fracture of a Caravel microcatheter. After a strategic pause and administration of intracoronary nitroglycerin, repeat angiography revealed a clearly visualized true lumen channel distal to the bifurcation. A dual-lumen microcatheter (Crusher double-lumen microcatheter, Boston Scientific) successfully redirected the guidewire into the distal true lumen, allowing completion of PCI using a double kissing crush (DKC) technique with restoration of TIMI-3 flow.

Keywords: Chronic Total Occlusion; Percutaneous Coronary Intervention; Double-Lumen Microcatheter; Subintimal Dissection; Microcatheter Fracture; Bifurcation PCI