Case 251: Manual of CTO PCI - RCA with tandem CTOs

A patient was referred for PCI of RCA CTO. There were 2 tandem occlusions: (a) from proximal to distal RCA and (b) in the right posterolateral. The PDA was filling via collaterals from the LAD that was in turn filling via a LIMA graft. The right posterolateral was filling via epicardial collaterals from the circumflex.
We used the “sequential dual guide technique”. Instead of using triple access, we obtained dual arterial access. We initially engaged the RCA and the LIMA that was filling the PDA and distal RCA. After crossing into the PDA using antegrade wiring with a Gladius Mongo, the LIMA catheter was replaced by a guide engaging the left main that allowed crossing of the 2nd CTO (in the right posterolateral).
Crossing of the 2nd CTO was challenging: antegrade wiring and ADR with a Stingray balloon failed. We successfully crossed an epicardial collateral from the circumflex with a Samurai RC and a Caravel microcatheter but there was too much back-and-forth movement of the microcatheter. The Caravel was exchanged for a Sasuke that enabled puncture of the distal cap with true-to-true wiring. After wiring externalization, balloon angioplasty, intravascular lithotripsy, and stenting a nice final result was achieved in the RCA. The integrity of the epicardial collateral was confirmed via injection through microcatheters inserted in both the antegrade and the retrograde direction.