[Retrograde angioplasty in chronic total occlusion].

The present article presents the case of a 70-year-old male, with a history of acute anterolateral myocardiac infarction (AMI) in 1986 and inferior AMI in 1992. Coronary arteriography was performed in 1995, which showed occlusion of the distal RCA and stenosis in 90% of the proximal LAD, with an ejection fraction (EF) of 29%. Balloon angioplasty was performed in the proximal LAD. The patient was admitted to hospital in 2007 with unstable angina. Coronary arteriography (Figure 1) showed occlusion of the distal RCA, 90% ostial lesion in the Cx, absence of restensosis in the LAD, and an EF of 25%. On February 2, 2007 angioplasty of the distal RCA (acute occlusion which had developed over 15 years in the collateral, isolateral, and contralateral arteries) was attempted, followed by an angioplasty on the lesion originating in the Cx (protected by reverse flow in the collateral arteries from the RCA to the Cx). The patient was receiving treatment with acetylsalicylic acid, clopidogrel, tirofiban, and low molecular weight heparin. A 7F JR4 guiding catheter was used (right femoral), as well as a 5F JL3.5 (left radial, to visualize the contralateral circulation from the left coronary artery). Since the 7F catheter did not provide sufficient support, a 5F JR4 one was used for the active catheterisation of the RCA. Following the administration of 8000 U of intracoronary heparin, an attempt to cross the lesion was made using Confianza Pro coronary guidewire (Asahi, Abott Vascular). The occlusion was crossed using an Avion OTW balloon (Invatec) and a Courier Microcatheter (Micrus Endovascular Corporation). Following a contralateral injection it was observed that the guidewire was located in false lumen and numerous failed attempts were made to move it to true lumen using the double-wire technique (Whisper guidewire, Abbott Laboratories; Pilot 50 Abbott Laboratories and Confianza Pro). Given that it was not possible to enter the true lumen, a retrograde angioplasty was performed via a septal branch. A Whisper guidewire was passed through the aforementioned branch to the distal bed of the left anterior descending artery (LAD) and the Courier microcatheter was subsequently passed through to this level. The lesion was crossed from the LAD using PTC Graphix guidewire (Boston Scientific), which was entered retrogradely through the RCA to the interior of the guiding catheter located in the RCA. Since the guiding catheter used was 100 cm (the length of which prevented it from reaching the balloon retrogradely in the obstructed area), the guide was retrieved using a snare (Amplatz goose neck, EV3). This was entered via the catheter positioned in the RCA. An attempt was made to reveal the guide using the snare via the guiding catheter in the RCA. This required a great deal of force and resulted in deep intubation in the left artery. The guide was fixed onto the snare, thus giving sufficient support to move the microcatheter retrogradely up to the 5F guiding catheter located in the RCA (Figure 2). A BMW guidewire (Abbott Laboratories) was then passed from the proximal RCA and entered into the microcatheter. The guidewire was passed to the septal branch via the microcatheter and subsequently removed leaving the guidewire in the distal LAD. A 1.25◊14 Avion ATW balloon was used to dilate the occlusion in the distal RCA. The balloon was inflated several times along the