Lots of interesting abstracts and cases were submitted for TCTAP 2026. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge!

CASE20251102_006

Successful Dual-Branch Revascularization for Unprotected Aorto-Ostial LMT CTO With Separated Bifurcation and No Retrograde Option Using Imaging-Guided Plaque Modification

By Hidenari Matsumura, Yuki Yamaguchi, Nobuhiro Yoshijima, Hiroaki Nishida, Erito Furuse, Takeshi Mori, Hiroyuki Yokota, Kenichiro Shimoji

Presenter

Hidenari Matsumura

Authors

Hidenari Matsumura¹, Yuki Yamaguchi¹, Nobuhiro Yoshijima¹, Hiroaki Nishida¹, Erito Furuse¹, Takeshi Mori¹, Hiroyuki Yokota¹, Kenichiro Shimoji¹

Affiliation

Saiseikai Utsunomiya Hospital, Japan¹

View Study Report

CASE20251102_006

Coronary - Complex PCI - Left Main

Successful Dual-Branch Revascularization for Unprotected Aorto-Ostial LMT CTO With Separated Bifurcation and No Retrograde Option Using Imaging-Guided Plaque Modification

Hidenari Matsumura¹, Yuki Yamaguchi¹, Nobuhiro Yoshijima¹, Hiroaki Nishida¹, Erito Furuse¹, Takeshi Mori¹, Hiroyuki Yokota¹, Kenichiro Shimoji¹

Saiseikai Utsunomiya Hospital, Japan¹

Clinical Information

Relevant Clinical History and Physical Exam

The patient was a 70-year-old man with a history of PCI to the right coronary artery and coronary artery bypass grafting using the Left Internal Thoracic Artery to the Left Anterior Descending artery (LITA–LAD). He had been stable on medical therapy, but developed exertional chest pain three months earlier. Despite medication adjustments, his symptoms gradually worsened, reaching Canadian Cardiovascular Society class II. The electrocardiogram showed nonspecific ST–T changes.

Relevant Test Results Prior to Catheterization

Echocardiography demonstrated ejection fraction of 40% with no asynergy and valvular disease. Laboratory evaluation showed preserved renal function and well-controlledlow-density lipoprotein levels. Cardiac computed tomography revealed occlusionof the LITA–LAD graft and a chronic total occlusion of the native left maintrunk beginning at the ostium. The distal cap was located at the bifurcation ofthe left main trunk into the LAD and LCX, with complete separation of the two branches.

Relevant Catheterization Findings

The left internal thoracic artery–left anterior descending artery (LAD) graft was completely occluded, and the native left coronary artery (LCA) was also occluded at the ostium of the left main trunk (LMT). The right coronary artery demonstrated no significant stenosis. From a right ventricular branch, non-interventional epicardial channels opacified the separated LAD and left circumflex artery. The occlusion length from the ostium of the long LMT to the bifurcation, was approximately 15 mm.

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Interventional Management

Procedural Step

First, percutaneous coronary intervention (PCI) was performed toward the left anterior descending artery (LAD). The initial antegrade wire deviated from the true lumen; therefore, parallel wire technique was employed to achieve successful crossing. To avoid jailing the left circumflex artery (LCX) ostium, the stent was deployed precisely at the LAD ostium, and the left main trunk (LMT) was dilated using a 4.0-mm cutting balloon.One month later, intervention toward the LCX was undertaken. Intravascular ultrasound (IVUS) performed from the LAD confirmed achronic total occlusion (CTO) entry with a markedly thick plaque covering the LCX ostium. Although the lesion was accurately marked, penetration with a high-penetration guidewire was unsuccessful. Even with the balloon screen technique using a CP 8-20, wire penetration remained unsuccessful. Therefore, plaque debulking was selected to expose the CTO entry. Directional coronary atherectomy (DCA) was performed, and follow-up IVUS demonstrated significant plaquethinning compared with baseline. Subsequently, the CP 8-20 wire advanced smoothly, enabling successful wire crossing. The procedure was completed usinga mini-crush stenting strategy.

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Case Summary

Aorto-ostial CTO of the LMT is extremely rare, accounting for approximately 0.1% of all CTOs. In this case, the lesion was particularly unique due to its unprotected LMT, absence of retrogradeoption, and completely separated distal bifurcation. In a bifurcation with separated branches, successful wire passage into one branch inevitably resultsin “short-cut” the entry of the other branch. In this case, cutting angioplasty could not modify the cap; therefore, directional coronary atherectomy (DCA) was employed. Although DCA is currently approved only in Japan, the essential concept is targeted plaque modification at the entry, which may also be achieved with other atherectomy modalities.

E-Case

CASE20251102_006