Letter to the Editor New strategy for a stumpless aorto-ostial chronic total occlusion Eduardo Alegría-Barrero, Pak Hei Chan, Carlo Di Mario ⁎ Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK article info Article history: Received 20 February 2012 Accepted 3 March 2012 Available online 27 March 2012 Keywords: Chronic total occlusion Percutaneous coronary intervention Coronary artery A 67 year-old woman was referred for persistent angina despite optimal medical therapy. Symptoms started 3 years prior to the refer- ral and were initially misinterpreted. Two years before coronary angi- ography was performed and revealed an occlusion of the RCA without any other significant lesion. First attempt was performed using ante- grade approach but the ostium could not be adequately visualised. A second attempt using contralateral injections followed, but again the high and posterior location of the origin of the RCA precluded catheter engagement and guidewire crossing despite the use of vari- ous shaped guiding catheters. Retrograde injections revealed a very tortuous atrial collateral originating from the left circumflex felt to be at high risk of failure and moderate risk of rupture for a retrograde approach. Rotational angiography with bilateral injection showed no stump of the ostium but evidence of competitive flow in systole clearing the contrast from the colateral injection. Thus, we decided for a new antegrade ap- proach. Knowing that none of the 8 variously shaped guiding cathe- ters were able to point towards the origin of the RCA, we switched to a multipurpose guiding catheter 8 F that pointed down and then inserted a 5 Fr Venture™ (St Jude Medical, St Paul, MN, USA) steering tip microcatheter to orientate, guided by contralateral injections, the tip of a Confianza Pro 12® (Ashahi Intecc Co, Japan) wire towards the ostium of the RCA. The wire crossed the ostial occlusion of the RCA International Journal of Cardiology 161 (2012) e21–e22 ⁎ Corresponding author at: Cardiovascular Biomedical Research Unit, Royal Bromp- ton Hospital, Sydney Street, SW3 6NP, London, UK. Tel./fax: +44 20 7352 8121, +44 7799067639 (mobile). E-mail address: c.dimario@rbht.nhs.uk (C. Di Mario). and could be advanced all the way down the distal posterior descend- ing artery, giving sufficient support for a 3.0 mm balloon to dilate the RCA ostium. Despite balloon predilation, we were unable to advance a stent due to complete lack of support of the guiding catheter with the wire floating in the aorta. Next, a 6-in-7 Guideliner™ catheter (Vascu- lar Solutions Inc, MN, USA) was inserted over the Confianza wire and advanced over a Monorail balloon inflated in the mid RCA into the proximal RCA. After implantation of a 3.5 × 18 mm Resolute Integri- ty® stent (Medtronic Inc, MN, USA) and despite postdilatation with a 4.0 × 8 mm non-compliant balloon at 30 atm with good balloon ex- pansion, the stent remained underexpanded at the ostium. In order to overcome this significant recoil a second 4.0 × 12 mm Resolute Integ- rity stent was implanted and expanded up to 4.5 mm with an accept- able angiographic result and a maximal diameter of 4.1 mm and MLA of 12.2 mm 2 in a final examination with intravascular ultrasound (Volcano Corp, San Francisco, CA, USA). The Venture™ wire control catheter is a 6 F-compatible catheter with a tip which can be deflected acting on the proximal handle. The coronary configuration with a small 2.5 mm tip bend radius al- lows interventional cardiologists to navigate complex turns in the artery, with examples including retrovert origin of the left circum- flex, wiring of side-branches jailed by deployed struts and orienta- tion of wires in the retrograde limb of the native arteries receiving a vein graft or a LIMA [1]. We also showed that the Venture catheter provides guidewire support when attempting to cross stumpless oc- clusions of vessels with large branches originating at the site of oc- clusion where conventional over-the-wire balloons or microcatheters will only straighten the wire down the side-branch [2,3]. To our knowledge, this is the first application of the Venture catheter to orientate the wire in the aorta through a stumpless ostial subocclusive lesion. We envision similar applications for ostial left main or SVGs occlusions using the 2.5 or 5.0 mm bend radius tips provided adequate localisation of the ostial occlusion is obtained (Figs. 1 and 2). In conclusion, the Venture steerable tip catheter can be helpful to orientate guidewires in extreme and complex coronary anatomies. References [1] Aranzulla TC, Sangiorgi GM, Bartorelli A, et al. Use of the Venture™ wire control catheter to access complex coronary lesions: how to turn procedural failure into success. EuroIntervention 2008;4:277–84. [2] Barlis P, Tanigawa J, Di Mario C. Successful crossing of an angulated lesion using a new deflectable-tip guidewire (Steer-IT). J Invasive Cardiol 2007;19(6):E154–5. [3] Tanigawa J, Galasko G, Goktekin O, DiMario C. A new steerable catheter to facilitate wire crossing through angulated chronic total occlusions. EuroIntervention 2007;1(1). 0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2012.03.009 Contents lists available at SciVerse ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard