Case 124: Manual of CTO interventions: Bifurcation distal cap + uncrossable + undilatable

A patient with mid LAD CTO was referred for CTO PCI to improve symptoms and left ventricular function. Antegrade wire escalation resulted in crossing into a septal branch at the distal cap. An attempt to redirect the guidewire into the LAD failed and the wire entered the subintimal space. It was eventually redirected into the septal. We attempted to deliver a TwinPass Torque without success. After dilation with a 1.5 mm balloon the TwinPass Torque was delivered to the distal cap, allowing successful wiring of the LAD using a Pilot 200 wire. The mid LAD was also balloon undilatable despite high pressure balloon inflation, but successfully expanded after inflating a Chocolate balloon at high pressure.

[dr.ahmedsaid]

Welcome back, 3 months since last case, we missed your valuable interesting cases

[jeddacath]

Did you use IVUS to assess the stent result/expansion

[ВалерийАлмаев-ул]

What should we do in situation, when we have not able to advance the guidewire into the true lumen of LAD, through the dual lumen microcateter and wire was into the subintimal space in this case? We have a bifurcation on distal cap and we try not to lose septal collateral perfusion. Can we use a stingray balloon? If yes - what level of advancing this device in this case? Thank you and excuse me for my question.

[denizaktürk-jn]

For simultaneous inflation of two small balloons in undilatable lesions how do you choose balloon size and lenght?