Case 205: Manual of CTO PCI - PK Papyrus fenestration

A patient was referred for PCI of native ostial RCA CTO due to recurrent failure of the SVG-OM1-PDA. An initial antegrade crossing attempt failed and a retrograde crossing attempt caused a perforation requiring implantation of a PK Papyrus DES along the PDA/posterolateral bifurcation.
A 2nd attempt was performed 6 weeks later: multiple antegrade wiring attempts failed despite using various guide catheters and wires and a guide extension. The Carlino technique resulted in modification of the proximal cap allowing advancement of a Gladius Mongo guidewire to the PDA/PLV bifurcation. A Hornet 14 guidewire successfully punctured into the right posterolateral but the PDA could not be wired. After stenting from the posterolateral to the RCA ostium retrograde wire crossing was attempted from the PDA into the distal RCA and vice versa with no success, as the retrograde guidewire kept on advancing to the right posterolateral. A 2-4 mm Microsnare was advanced antegradely to the right posterolateral snaring the retrograde guidewire and pulling it back into the antegrade guide catheter. After externalization of an R350 wire, the culotte technique was used to stent the PDA/posterolateral bifurcation with a nice final result.