Percutaneous Coronary Intervention of Chronic Total Occlusion With Retrograde Approach
Follow-Up by Cardiac Magnetic Resonance Imaging
A 59-year-old hypertensive male ex-smoker with diabetes mellitus and a family history of coronary artery disease was referred to our center for percutaneous coronary intervention (PCI) of a known chronic total occlusion (CTO) of the proximal right coronary artery. There was no significant disease in the left coronary system. A Tc-tetrofosmin myocardial perfusion scan was performed. The images after stress revealed severe ischemia of the mid and basal inferior wall.
An anterograde approach failed, so recanalisation of the right coronary artery was attempted via a retrograde approach through the septal collateral. The septal perforation is seen in Figure 1A. PCI was successful with implantation of 4 CYPHER stents (Cordis, Miami Lakes, Fl) (2.75×23 mm, 3.0×33 mm, 3.5×22 mm: in the mid segment and 3.15×13 mm at the ostium). There was TIMI 3 flow at the end of the procedure (Figure 1B). The baseline and post procedure ECGs did not show any significant differences (Figure 2A and B). At 24 hours after PCI, there was a peak of cardiac enzymes (troponin I : 1.19 μg/L [<0.04], CK-MB : 7.8 μg/L [0–6]).
An initial cardiovascular magnetic resonance (CMR) scan was done 48 hours after PCI, and showed evidence of septal mid-wall late gadolinium enhancement (Figure 3A: arrow 1) compatible with the septal perforation. In addition, there was a chronic inferior wall subendocardial infarct (Figure 3A: arrow 2). A follow-up CMR scan was performed 8 weeks after the procedure and showed a small area of focal fibrosis in the mid septum at the site of previous intervention (Figure 3B: arrow 3). This is less prominent than seen on the previous scan and is likely to represent infarct resorption and a reduction in the amount of associated inflammatory changes.1 There was no inducible ischemia on the stress perfusion scan images (Figure 4: stress and correlating rest images).
Among all patients who undergo coronary arteriography, CTO is present in at least 30% of cases.2,3 Coronary CTO remains one of the most challenging lesion subsets in interventional cardiology,4–6 even with the development of medical devices and operator expertise, although the long term outcome of PCI for CTO is currently unknown. This case shows the benefit of CMR, a safe, noninvasive technology, for the follow-up and assessment of the efficacy of a complex PCI procedure like CTO.
Dr Prasad has received grants from CORDA and the British Heart Foundation.
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