Treatment of LAD With Investment Procedure in a Patient With Failed CTO Attempt With TIMI 0 Flow

Key words: chronic total occlusion, investment procedure, subintimal plaque modification

A 48-year-old male patient with a known diagnosis of hypertension presented after 6 months of chest pain (Canadian Cardiovascular Society II-III). Coronary angiography (CAG) showed a chronic total occlusion (CTO) of the left anterior descending (LAD) coronary artery from the mid-region (Figure 1 and Video Series). Percutaneous coronary intervention (PCI) was planned upon detection of viable tissue with myocardial perfusion scintigraphy. The distal portion of the CTO lesion was passed with microcatheter support and a hydrophilic wire. Distal flow could not be achieved despite successive predilations with small-diameter balloons (Figure 2). It was decided to implement an investment procedure to facilitate the next PCI process. Control angiogram 6 months later showed Thrombolysis in Myocardial Infarction (TIMI) 3 flow in the distal lumen of the LAD and there was no residual stenosis (Figure 3). 

Subintimal plaque modification to restore some antegrade flow can promote subsequent lesion recanalization (investment procedure) in cases of failed re-entry into the distal true lumen during CTO-PCI. In this case, we aimed to present a case in which TIMI 0 flow was observed in the LAD after unsuccessful PCI attempt, but was left to recover with the investment procedure and TIMI 3 flow was detected in the control angiogram. In unsuccessful PCI-CTO cases, even in the presence of TIMI 0, flow can improve in the future through an investment procedure.