Case 215: Manual of CTO PCI - On your toes...

A patient was referred for PCI of a RCA CTO after a prior failed attempt. The CTO had a blunt but clear proximal cap, length of approximately 15 mm, good quality distal vessel with heavy calcification and septal collaterals. Antegrade wiring failed. Entering a septal collateral was challenging, but eventually succeeded using the reversed wire technique. Septal surfing failed, hence we tried to cross a more distal collateral that was successfully crossed using a contrast-guided strategy. After advancing a Turnpike LP to the distal cap the patient developed chest pain and ST segment depression (prior LAD iFR was 0.91). The Turnpike LP was withdrawn (leaving the retrograde wire in place) and the chest pain and ECG changed resolved. We had difficulty advancing antegrade wires, balloons, and guide extensions, but using the inchworming technique a guide extension was delivered to the proximal RCA and guide extension reverse CART was successfully performed, followed by RCA stenting with an excellent final result. RFR of the LAD was 0.86 with gradual step up on pullback, hence no PCI was performed in the LAD.