CT-Angiography Fusion During Coronary Chronic Total Occlusion PCI

J INVASIVE CARDIOL 2022;34(3):E255-E256.

Key words: CT-angiography fusion, hybrid approach

A 56-year-old male presented with angina pectoris despite optimal medical treatment. A coronary computed tomography (CT)-angiography revealed a chronic total occlusion (CTO) of the proximal right coronary artery (RCA) with a moderately calcified long path, and a CTO of the distal circumflex (Figure 1A and Figure 1B). Distal RCA was identified by well-developed collaterals, and we planned CTO percutaneous coronary intervention. We decided to merge CT-angiography images with fluoroscopy to facilitate a hybrid approach.

After simultaneous catheterization by biradial access (Figure 1C), distal RCA was gained from the left descending artery through the septal branches. Using fusion of the CT-angiography and fluoroscopic images helped to enter the true lumen of the RCA with few uses of iodinated contrast and fluoroscopy time. This technique also allowed a precise evaluation of the wire path and the prediction of the most relevant radiological projections. After entering the true lumen, we advanced guidewires with a retrograde and antegrade approach to perform a controlled antegrade and retrograde tracking-reverse technique and advance the retrograde wire into the antegrade catheter (Figure 1D). An arterioarterial loop was created, followed by predilatation and stent implantation (Figure 1E and Figure 1F). CT-angiography allows a better measurement of the length and diameters of the stents.

In selected cases with long occlusions and the need for a hybrid approach, the use of CT-angiography fusion could help to identify the right wire position, prevent perforations, reduce the use of contrast and fluoroscopy time, improve patient safety, and increase success rate.

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