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TCTAP C-043 . Presentation


Hong Nyun Kim


Hong Nyun Kim1, Hun Sik Park1, Jang Hoon Lee1


Kyungpook National University Hospital, Korea (Republic of)1,
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CORONARY - Chronic Total Occlusion

Knuckle – Wire Technique for Chronic Total Occlusion Lesion

Hong Nyun Kim1, Hun Sik Park1, Jang Hoon Lee1

Kyungpook National University Hospital, Korea (Republic of)1,

Clinical Information

Patient initials or Identifier Number


Relevant Clinical History and Physical Exam

A 57-year-old male admitted to our hospital, because he had dyspnea on exercise (DOE) for 2 months. The patient had a history of hypertension and dyslipidemia and was a smoker. He was diagnosed with unstable angina 2 months ago and received PCI or Left main to proximal LAD. At that time, the CAG showed chronic total occlusion in mid RCA. After the PCI, the patient’s chest pain improved, but DOE still persisted.

Relevant Test Results Prior to Catheterization

ECG: Normal sinus rhythm, Heart rate 70bpm, No specific ST segment abnormalityCardiac enzyme: CK-MB 1.5 ng/mL, TroponinI <0.015 ng/mLEchocardiography: Normal LVEF (51%) and hypokinesia of basal inferior wall and basal septum

Relevant Catheterization Findings

The CAG showed that chronic total occlusion in mid RCA, mild stenosis in proximal RCA. There was no in-stent restenosis in the LM to LAD previous stent.

Interventional Management

Procedural Step

The PCI was performed with both transfemoral approach. A 7Fr EBU 3.75 guiding catheter was inserted through the left coronary artery and a 7Fr AL 1 guiding catheter was used for right coronary artery. We initially tried an antegrade approach for mid RCA CTO lesion, using a Sion Blue guidewire with Caravel microcatheter. But the Sion Blue guidewire couldn’t pass the lesion, so we had to change the guidewire to Sion, XT-R, Ultimate 3, and Gaia second guidewire. But we failed wiring over the CTO lesion. So we changed the strategy and tried a retrograde approach through the LAD septal channel. Sion, SUOH 03 guidewire, and Caravel microcatheter were used for retrograde wiring. After reaching the distal cap of CTO lesion, we exchange the retrograde guidewire to Fielder XT-R.  After that, we made a knuckle formation on retrograde Fielder XT-R wire in subintimal space, then antegrade guidewire, Gaia second, was led inside subintimal space. Finally, we could pass the guidewire to distal part of RCA. After that, we checked IVUS and performed pre balloon dilatation using 1.0 x 10mm and 2.0 x 20mm balloon. Finally, we implanted Synergy, 2.5 x 38mm, 3.0 x 38mm, 3.5 x 24mm stent to the distal to proximal RCA, and we could get TIMI 3 blood flow.

Case Summary

A successful guidewire crossing through the total occlusive lesion was indispensable for successful PCI. Recently, the success rate of CTO procedure is increasing due to improved technology and equipment, but sometimes, it is very difficult to wiring the target vessel.In this case, we performed the retrograde wiring using the knuckle wire technique and successfully finished the PCI.

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TCTAP 2021 Virtual Apr 12, 2021
Congratulations on the successful result!