Case 263: Manual of CTO PCI: Dissection to treat perforation

A patient was referred for PCI of a RCA CTO. The CTO had a blunt proximal cap, long length and good quality distal vessel that was filling via both septal and epicardial collaterals. Antegrade crossing with a Fielder XTA and Gaia Next 1 failed. Retrograde crossing attempts through septal collaterals also failed. A Fielder XT wire was knuckled antegradely along what appeared to be the mid RCA. A Stingray balloon was delivered and re-entry was attempted with the double blind stick and swap technique but coronary angiography showed that the Stingray was outside the RCA and there was “staining” suggestive of perforation. A balloon was inflated in the proximal RCA for hemostasis. Repeat retrograde attempts failed. Using the “BASE” technique a Gladius Mongo wire was advanced to the distal RCA, followed by successful reentry using the Stingray balloon. Stenting resulted in sealing of the perforation with a nice final result.
Creating a dissection flap is an alternative way to seal a coronary perforation.

[shangz]

Thanks for the excellent case presentation.

[Hanin]

Brilliant technique , , very nice Manos, However this only applies to perfs happening within context of CTOs
Thanks lovely case !!

[wbcjunior]

Would you recommend getting an injection after starting Knuckle?
this is safer after evaluating the wire dancing with the vase