A patient with prior CABG was referred for PCI of a circumflex in-stent CTO. Crossing through the stent failed despite using multiple guidewires. Eventually a Sion black was knuckled and crossed around the stent into the subintimal space. Microcatheter delivery was challenging resulting in microcatheter tip deformation. Eventually a Turnpike LP was advanced in the subintimal space distal to the stent. Delivering a Stingray balloon was very challenging but eventually succeeded. Re-entry was also challenging in part due to challenging equipment delivery and in part due to poor visualization of the distal vessel. Confirmation of distal true wire position was done via transducing the pressure through the microcatheter. The first time a flat waveform was seen suggestive of subintimal position. The second time an arterial waveform was seen confirming distal true lumen crossing.
Delivering balloon and stents was challenging but succeeded after multiple balloon inflations and use of a guide extension. A distal vessel perforation was seen in the distal circumflex. Attempts for delivery of a covered stents were complicated by fracture of the Trapliner push rod and of a the shaft of a Graftmaster covered stent. Both device fragments were retrieved. Eventually a Graftmaster stent was preloaded into a 6 French Guideliner and successfully delivered distally sealing the perforation.
