A patient was referred for PCI of a proximal circumflex CTO. The CTO had a clear proximal cap, length of about 30 mm, distal cap at a bifurcation and within a prior stent and diseased distal vessel filling via bridging, non-interventional collaterals. A wire was advanced into the circumflex using a SuperCross 120 but the microcatheter could not follow due to poor support. A Turnpike LP and Corsair also failed to follow but a FineCross M3 did. Hydrodynamic recanalization did not facilitate wire advancement. Eventually a Sasuke could be advanced into the circumflex allowing more distal wire advancement and then a large single lumen microcatheter could be delivered into the circumflex. After multiple attempts a guidewire was advanced into the OM1. Wiring of the distal circumflex through a Sasuke failed, as the wire kept on entering into a small branch originating at the distal cap. Eventually the Sasuke was advanced over the branch wire and the distal circumflex was successfully wired. The circumflex was predilated and treated with a DCB with a satisfactory result.
The patient had chest pain few hours later. Angiography showed a left main dissection that was successfully stented.