Left Circumflex CTO


  • This 53 year old lady presented with angina
  • The Nuclear stress test showed large area of ischaemia in the lateral and inferior wall
  • Coronary CT scan showed significant LCx vessel disease
  • The 1st attempt in another hospital was via right radial route
  • Only antegrade wiring with up to 2 wires were attempted
  • This attempt was not successful

The 1st angiogram
5F Tiger diagnostic


The wire is in the sub-intimal space
6.5F Sheathless Eaucath PB 3.0 with Miracle 6 wire over
Finecross microcatheter


LAO view shows wire is not in vessel
Final attempt with Gaia 2nd wire
Procedure was abandoned



  • After studying the angiogram for the 1st failed attempt
  • I felt that a retrograde approach should result in success as there is adequate collateral filling
  • There is another lesion in the proximal LAD which will also need to be treated
  • The 2nd attempt should be via the groin approach as a 7F catheter is needed

The 2nd attempt
7F AL2 guide
Angio shows the collateral channels


Wiring the septal channel
Sion on Corsair entering septal

Angio shows the collateral channels


Bidirectional wiring
Sion in LCx stump
Fielder XT-R in retrograde crossing


RAO caudal and Left Lateral views
Gaia 2nd crossed into LCx and 2 orthogonal views are used to verify that the retrograde wire has entered true lumen

The whole LCx and OM2 branch are now visible
RG3 externalised and LCx dilated with Ikazuchi 2.5 x 15mm balloon


OM2 is wired and treated with Drug-Eluting Balloon
Run through in LCx, Fielder FC in OM2
OM2 is treated with Sequence Please 2.5 x 20mm DEB


Using Intra-Vascular Ultrasound (IVUS) to identify the ostium for OM1
OM1 ostium entered with Fielder FC. CTO segment crossed with XT-A over Corsair


After dilatation of OM1
OM1 dilated with Ikazuchi balloon 2.5 x 15


Stent placed across OM1 and OM2 in the Left Circumflex artery
Xience 3.0 x 38 placed in LCx jailing both OM1 and OM2 wires


Completing the treatment of LCx

  • OM1 2.5 x 15 and
  • LCx 3.0 x 15 kissing balloon performed
  • The OM1 was then stented with Absorb 2.5 x 12 Bio-absorbable stent
  • The pLAD was also stented with Absorb 3.0 x 18 BVS


The final angiogram
RAO caudal view showing complete revascularization of the Left Circumflex artery


Final angiogram
The whole LCx is now completely visualised


Comparison of Before and After
The occlusion before stenting



  • This case illustrates how a chronic total occlusion (CTO) of a vessel can be treated using ‘Retrograde’ wiring approach
  • This technique is time consuming and requires high level of skill and patience
  • However, if successful, it can open up completely blocked arteries
  • In this case, not only is the main artery is opened, the branches are also successfully opened
  • The standard antegrade approach was used for treating the OM1 branch