Multimodality imaging-guided recanalization of a complex left anterior descending chronic total occlusion

A 66-year-old woman with a history of type 2 diabetes mellitus, arterial hypertension, and aorto-iliac occlusive disease was admitted for planned recanalization of a chronic total occlusion (CTO) of the left anterior descending artery (LAD) (J-CTO score 3) (Figure 1 C). She presented with Canadian Cardiovascular Society (CCS) class III angina without dyspnea, and left ventricular systolic function was preserved.

Figure 1.

Multimodality imaging-guided recanalization of a complex chronic total occlusion (CTO) of the left anterior descending artery (LAD). A – Coronary computed tomography angiography demonstrating the course of the occlusion (left anterior oblique/caudal view) and the distribution of calcium along the lesion, with “full moon” calcification of the proximal cap. B – Cardiac magnetic resonance demonstrating preserved viability (absence of late gadolinium enhancement) and ischemia (perfusion defect marked in red). C – Angiographic views demonstrating the pre-procedural image, the final procedural result, the interventional septal collateral used for retrograde crossing (marked in yellow), and the microcatheter advanced through the collateral (asterisk). D – Intravascular ultrasound demonstrating central puncture of the distal cap and extraplaque puncture of the heavily calcified proximal cap; the images correspond to the calcium distribution on computed tomography cross-sections

A previous percutaneous coronary intervention attempt using Fielder XT-A and Gaia Next 2 guidewires had been unsuccessful, with both wires entering the subintimal space. Before the current procedure, cardiac magnetic resonance (CMR) imaging confirmed preserved myocardial viability in the LAD territory (Figure 1 B). Coronary computed tomography angiography (CCTA) delineated the course and length of the occlusion (Figure 1 A) and identified a heavily calcified proximal cap with a nodular “full moon” calcium configuration – which may have contributed to guidewire deflection into the subintimal space during the prior antegrade attempt. In contrast, the distal cap was less calcified, displaying focal fibrous tissue and a “crescent moon” calcium morphology. Based on these findings, a retrograde strategy was considered the most feasible approach.

The procedure was performed via bilateral radial access. The distal cap was reached using a SUOH 03 guidewire advanced through a septal collateral channel. A Corsair Pro XS microcatheter was then advanced, and the guidewire was exchanged for a Gaia Next 2 wire for distal cap puncture. The wire was subsequently navigated through the occlusion using the reverse controlled antegrade and retrograde subintimal tracking (reverse CART) technique, enabling re-entry into the proximal true lumen, where an antegrade Gaia Next 2 wire was then advanced. The lesion was predilated with 0.75 mm and 2.0 mm semi-compliant balloons, followed by a 3.0 mm non-compliant balloon. Intravascular ultrasound (IVUS) revealed a significant plaque burden extending from the ostium of the left main coronary artery to the mid-LAD. Accordingly, a 3.5 × 40 mm everolimus-eluting stent was implanted from the left main ostium to the LAD, followed by two overlapping everolimus-eluting stents (3.5 × 15 mm and 3.5 × 18 mm) in the LAD. The left main trifurcation was optimized using a 5.5 mm balloon, followed by final kissing balloon inflation (4.0/3.0/3.0 mm). Final IVUS and angiography confirmed an optimal procedural result (Figure 1 D). The patient was discharged in good clinical condition and remains angina-free at 1-year follow-up.

This case highlights the complementary role of non-invasive cardiac imaging in both patient selection and procedural planning for CTO recanalization. CMR enables accurate assessment of myocardial viability in the territory supplied by the occluded artery, which is particularly valuable when echocardiographic findings are inconclusive. The extent of late gadolinium enhancement (LGE) is a key predictor of functional recovery after revascularization; segments demonstrating < 50% transmural LGE show the highest likelihood of improvement in left ventricular function following CTO recanalization [1].

CCTA provides detailed visualization of the occluded vessel segment, which is frequently incompletely characterized by conventional angiography alone. It allows precise assessment of occlusion length, vessel course, angulation, calcification distribution, and the presence of tandem lesions. In complex CTOs – especially after failed antegrade attempts – CCTA can identify anatomical features responsible for procedural failure. In the present case, recognition of the heavily calcified proximal cap explained the prior guidewire deflection and directly informed the strategic shift to a retrograde approach. Integration of CCTA findings into procedural planning has led to the development of the CT-RECTOR score, which has demonstrated superior predictive accuracy for time-efficient guidewire crossing and CTO difficulty compared with the widely used J-CTO score [2]. Moreover, CCTA has shown good agreement with intravascular ultrasound in assessing reference vessel diameter, which may facilitate pre-procedural stent sizing and optimization strategies [3, 4].

In complex CTO interventions, a multimodality imaging approach – combining CMR for viability assessment, CCTA for anatomical characterization, and IVUS for intraprocedural optimization – may enhance procedural success while improving safety and long-term outcomes. This case underscores how detailed pre-procedural imaging can refine strategy selection and contribute to successful revascularization in challenging CTO anatomy.

Funding Statement

Funding No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.