Case 174: Manual of CTO PCI - Beware of stiff guidewires...

A patient presented with in-stent restenosis at the distal anastomosis of a saphenous vein graft to the diagonal branch that was also supplying the LAD and was referred for PCI of the LAD CTO. The LAD had a flush occlusion at the ostium. Retrograde crossing was attempted via the SVG. The distal cap could not be punctured despite using a Mongo and Gaia 2nd guidewire. A Hornet 14 wire was used to puncture the distal cap followed by a Gaia 3rd that appeared to advance subintimally to the left main. Antegrade puncture attempts using the retrograde guidewire as maker the vessel location failed and caused a perforation that was sealed with implantation of a PK Papyrus covered stent. Injection of the SVG showed another perforation at the distal cap. Attempts to deliver an Axium coil failed. Another PK Papyrus covered stent was delivered using a Guideliner and deployed across the area of perforation sealing the perforation. Another DES was placed in the SVG distal anastomosis at the site of in-stent restenosis followed by kissing balloon inflation.