Percutaneous Coronary Intervention for Left Main Chronic Total Occlusion: Unprotected or Protected Case?

J INVASIVE CARDIOL 2023;35(4):E219-E220.

Key words: bifurcation stenting, chronic total occlusion, left main

A 60-year-old male with chronic obstructive pulmonary disease and active smoking was admitted for positive treadmill test. He reported exertional chest pain 4 months ago; however, since then he had been symptom free. Echocardiography showed severe anteroseptal and mild inferoposterior hypokinesia, preserved wall thickness, and moderately reduced left ventricular ejection fraction. Coronary angiography revealed non-calcified chronic total occlusion (CTO) of the left main (LM) with microchannel toward the left circumflex (CX) artery (Figure 1A). Dominant right coronary artery (RCA), free of significant stenosis, supplied both left anterior descending (LAD) artery and CX with abundant transseptal and epicardial collaterals (Figure 1B). LAD and CX ostia were patent. Per the patient’s preference, we opted for percutaneous coronary intervention (PCI). The RCA was cannulated with Judkins 4.0, 6-Fr guiding catheter (left radial approach), LM with EBU 4.0, 7 Fr (right femoral approach; right radial approach failed). By using the antegrade-wire escalation technique, the LM was negotiated with a Fielder XTR (Asahi Intecc); however, only the CX could be accessed. After exchange for a Grand Slam wire (Asahi Intecc), balloon dilation with a non-compliant (NC) balloon up to 4.0 mm (Figure 1C) and wiring of the LAD with a Pilot 50 wire (Abbott) ensued. An Onyx 3.5- x 30-mm drug eluting stent (Medtronic) was implanted from the LM ostium toward the LAD (Figure 1D), followed by proximal optimization technique (POT)-kissing-POT sequence (NC 5.0 mm for POT). Technical and procedural success were obtained (Figures 1E, 1F and Video 1).

Oligosymptomatic or asymptomatic patients with unprotected LM-CTO are rarely encountered.¹ We suggest that “functional protection” with potent collaterals, in addition to other favorable features, such as low/intermediate SYNTAX score (29), low Japan-CTO score (1), and absence of diabetes, should promote a PCI strategy. Long-term results of such PCIs are to be determined.

Reference

1. Xenogiannis I, Karmpaliotis D, Alaswad K, et al. Left main chronic total occlusion percutaneous coronary intervention: a case series. J invasive Cardiol. 2019;31(7):E220-E225.

Affiliations and Disclosures

From the Department of Cardiology, Dubrava University Hospital, Zagreb, Croatia.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted September 15, 2022.

Address for correspondence: Marin Pavlov, MD, PhD, Department of Cardiology, Dubrava University Hospital, Avenija Gojka Suska 6, 10000 Zagreb, Croatia. Email: marin.pavlov@gmail.com