Failed CTO, Retry or not? 2. My Experience

초록

Case Presentation A 73 years-old woman was admitted for dyspnea combined with chest pain for several days. She had past history of hypertension and old myocardial infarction 20 years ago. However, she had not undergone coronary angiography at that time. Initial BP was 165/137 mmHg and HR was 147 bpm. Initial cardiac biomarker levels were as follows: CK 688 IU/L, CK-MB 32.2 ng/mL, TnI 8.8 ng/mL. Electrocardiography revealed atrial fibrillation with rapid ventricular response. Chest X-ray revealed cardiomegaly with pulmonary edema. So under the diagnosis of NSTEMI, we performed coronary angiography. Coronary angiogram: Left coronary angiogram showed total occlusion of LAD and 80% stenosis of LCX. Right coronary angiogram showed minimal disease of RCA with good collateral flow from d-RCA to d-LAD (Rentrop grade 3). 1st attempt: Right coronary artery was engaged with a 7 Fr AL-1 guiding catheter and left coronary artery was positioned with a 7 Fr EBU guiding catheter through the bi-femoral approach. We tried to reach the distal cap of the CTO lesion through septal branch using Sion wire with Cosair® microcatheter. Then, we used guidewires Fielder XT and Gaia first, but failed to penetrated into the true lumen of pLAD. So, we performed Reverse CART using PTCA balloon 2.0X15 and the wire penetrated the lesion successfully. After advancement of microcatheter into the left guiding catheter, and wire externalization was performed. However, during wire externalization, ventricular fibrillation occurred. Even after several times of defibrillation and cardiopulmonary resuscitation, ROSC was not achieved, so we decided to stop the procedure. Question: What is the reason for cardiac arrest d/t VF during wire externalization? How can we prevent this situation and what should we be aware of? 2nd attempt: The patient was sent to CCU, and ROSC was achieved. ECMO and CRRT was applied. 1 week later, we re-tried LAD CTO lesion under ECMO and CRRT support.