A patient presented with recurrent NSTEMIs. Ejection fraction was 25%. The patient was turned down for CABG and referred for PCI. Coronary angiography showed 3-vessel coronary artery disease with lesions in the left main and CTO of the mid LAD, mid circumflex and mid right coronary artery. Cardiac MRI demonstrated viability in most myocardial territories. It was decided to perform PCI of the circumflex CTO first. Right heart catheterization showed normal pulmonary capillary wedge pressure, hence no prophylactic support was used, however VA-ECMO was on standby.
The mid circumflex CTO had a blunt proximal cap at the bifurcation of the first obtuse marginal branch. Attempts to cross the CTO with a Turnpike Spiral microcatheter and a Fielder XT-A guidewire resulted in OM1 dissection, compromising antegrade flow and resulting in hypotension. VA-ECMO was initiated stabilizing hemodynamics. A Sion blue guidewire could then be reinserted into the first OM1 as confirmed by IVUS restoring antegrade flow after balloon angioplasty. Repeat attempts to cross the mid circumflex CTO resulted in subintimal guidewire crossing. A Miracle 6 guidewire was inserted to facilitate delivery of a Stingray balloon and caused a perforation in the mid circumflex. A balloon was inflated proximally to stop antegrade flow, followed by a brief retrograde attempt that failed. Blood extravasation persisted despite prolonged balloon inflation. A polymer-jacketed guidewire was advanced subintimally to the mid/distal circumflex, but Stingray-based re-entry failed. A knuckled wire was then advanced to the second obtuse marginal branch, followed by successful re-entry using the “double-blind stick and swap” technique. After stenting the perforation was sealed. The patient developed lower extremity ischemia from the arterial VA-ECMO cannula, but eventually recovered.
