A Phantom Menace


  • One of the most important steps while performing CTO PCI is the capturing of good angiogram
  • In the LAO view angiogram, there appears to be a decent channel connecting the ostium of the RCA to the mid portion without any break

LAO view

Even from the left lateral view it looks as though there is a decent track

Using a Gaia 2nd to enter the proximal cap
This looks almost like a 5-minute job

But we were deceived when looking from the AP cranial view

The wire is maneuvered to the other side

But from the Lateral view, the wire is too low

Actually, there is no definite entrance into the CTO
The Conquest Pro wire is now abutting the stump

A change of tact was required
There was a RPL branch which joins the RCA

Entered the PDA 1st and then adjusted wire into the distal RCA

  • Injection of dye into the Corsair shows that although the length of the CTO was short, it was definitely there
  • This was our phantom menace which was not obvious from the bilateral injection angiogram

  • The CTO segment was so calcified that Gaia 2nd was unable to make any progress
  • A Conquest Pro 12 was required for the retrograde crossing
  • At this stage, the 2 wires look incredibly closed to each other but in CTO terms, they are still miles apart

  • Eventually the Conquest Pro crossed the CTO and entered the aorta
  • It is then pulled back to enter the antegrade catheter

  • Sequential balloon dilatations were performed starting with 1.5mm and then 2.5mm semi-compliance balloon

  • A 3.0 x 33 stent was chosen

  • This is the final result in AP Cranial view

  • The final result in Left Lateral view


  • Ostial RCA CTO’s are challenging to treat
  • This is because it is difficult for the RCA guide to provide sufficient support to push the wire
  • Retrograde crossing usually provides a better chance of success
  • However, the direction the retrograde wire needs to traverse is sometimes difficult to determine
  • This is due to the fact that the origin of the RCA ostium and the 1st few millimeters where the RCA travels are variable
  • Our case demonstrates that good angiography is very important as there are a number of views where the retrograde filling almost overlaps with the antegrade giving the misconception that the CTO may not exist
  • Naturally we already knew in the beginning from the unilateral injection that there is a definite CTO
  • Also fortunately the very short RCA stump allows us something to aim at for the retrograde crossing