A patient was referred for PCI of a proximal circumflex CTO due to medically refractory angina. He had a patent radial graft to an obtuse marginal branch, but there was a significant lesion at the origin of the OM1, limiting flow to the distal circumflex that was a large vessel.
Antegrade wire escalation attempts failed due to severe calcification. A Turnpike LP microcatheter was advanced retrograde, but reverse CART failed due to significant calcification and guide position was lost. The radial graft was re-engaged using a guide extension and repeat retrograde attempts were performed that failed despite using up to 4.0 mm antegrade balloons. Antegrade dissection/re-entry was attempted, but re-entry into the distal circumflex failed. A repeat retrograde attempt starting the dissection more distally in the vessel was eventually successful in crossing, but the distal circumflex could not be wired (“Pyrrhic victory”). Eventually subintimal plaque modification was performed in the circumflex with restoration of TIMI 2 flow without stent implantation with plans for repeat CTO PCI attempt in 2-3 months.
