A Full DCB Approach in RCA-CTO Supported by TrueCross™ Microcatheter and TrueExtensio™ Ultimate GEC
Prof. DING Fenghua
Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, China
Introduction
As complex coronary interventions continue to evolve, complex lesions such as CTOs, severe calcification, and tortuous vessels are increasingly encountered. Device delivery is frequently compromised by vessel tortuosity, inadequate backup support, and increased crossing resistance — making it difficult to advance DCBs and stents to target lesions, thereby increasing procedural complexity and duration. Establishing a stable delivery system and ensuring reliable device access under complex anatomical conditions have become critical determinants of PCI success.
This case was performed by Prof. Ding Fenghua from Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. The TrueCross™ microcatheter and TrueExtensio™ Ultimate balloon guide extension catheter (Insight Lifetech Co., Ltd. ) provided dual-support: the TrueCross™ delivered stable backup to facilitate wire crossing of the CTO lesion and establish an antegrade pathway, while the TrueExtensio™ Ultimate provided deep intubation plus anchoring to enhance support, shorten device delivery distance, and improve DCB deliverability, ensuring successful CTO recanalization.
Patient Profile
Sex/Age: Male, 56 years old.
Chief Complaint: Recurrent chest tightness for 2 years, with a recurrence in the past week.
History: Onset of chest tightness with precordial chest pain 2 years ago, recurring thereafter. CAG + PCI + IVUS performed on 2025-03-21; one stent implanted in LAD and one in LCX, respectively.
Risk Factors: Hypertension, Diabetes.
Diagnostic Findings
ECG: Normal
Laboratory:
CK: 74 U/L
Troponin T: 7.34 pg/mL
CK-MB: 10.6 U/L
Creatinine: 63 μmol/L
Triglycerides: 4.03 mmol/L
HDL-C: 0.91 mmol/L
Total cholesterol: 4.39 mmol/L
Diagnosis: Unstable angina
Angiographic Findings_RCA
RCA angiography: 90% stenosis in the proximal-to-mid RCA with ulceration; 100% occlusion in the distal segment; ipsilateral collaterals present.
Angiographic Findings_LCA
LCA angiography: LM without significant stenosis; LAD previously stented and patent, with contralateral collaterals visible distally;
LCX previously stented and patent.
Procedural Challenges
Plaque ulceration in the proximal-to-mid RCA, suggestive of plaque rupture.
Tortuous distal RCA occlusion, complicating wire navigation.
Ambiguous CTO ostium with contralateral collaterals originating from the LCX.
Side branch at the CTO entry point, limiting conventional antegrade approaches.
Poorly visualized retrograde collaterals, further increasing procedural complexity.
Procedural Strategy
Consider hydraulic dissection to assist antegrade guidewire crossing.
Utilize intravascular imaging to confirm true-lumen wire position.
Enhance backup support through guidewire anchoring and deep intubation of GEC.
Bilateral angiography
Bilateral injection confirmed RCA occlusion extending to the crux. The TrueCross™ microcatheter supported antegrade wire navigation with an XT-R wire.
Selective Angiography & Hydraulic Dissection
The CTO entry point was unclear with a branch at the ostium.
XTR entered the CTO body.
TrueCross™ microcatheter was advanced into the occlusion.
Hydraulic dissection was then initiated to facilitate crossing.
PL Branch Recanalization
Crossing: With TrueCross™ support, wires were sequentially upgraded (Pilot 150, then UB3) to successfully cross the PL. The microcatheter was advanced, and the wire was exchanged for a workhorse guidewire.
PTCA predilation: A 2.0 × 20 mm balloon was used with adequate expansion. Angiography confirmed satisfactory lesion preparation.
RCA-IVUS Assessment
Insight Lifetech TRUEVISION™ IVUS imaging revealed organized thrombus in the proximal-to-mid RCA, with a plaque burden of 87% in the proximal segment.
PDA Recanalization
Under TrueCross™ microcatheter support, the XT-R successfully crossed into the PDA. The lesion was fully predilated with a 2.5×15 mm balloon at 12 atm. Angiography confirmed good predilation results.
DCB Angioplasty of PL Branch
Given the distal location of the lesion, calcified and tortuous vessel anatomy, and the long delivery path, a 6F TrueExtensio™ Ultimate balloon guide extension catheter was deployed in advance to establish a stable delivery platform. This enhanced system support, reduced DCB delivery resistance, and minimized drug loss. Two DCBs (2.5 × 40 mm and 2.5 × 38 mm) were successfully delivered to the PL lesion and inflated at 6–8 atm for 60 seconds each.
DCB Angioplasty of PDA
TrueExtensio™ Ultimate was further deep-intubated and anchored to the mid-to-distal RCA.
A 2.75×40 mm DCB was delivered to the PDA stenosis and inflated at low pressure for 60 seconds.
DCB Angioplasty of RCA
With the support of TrueExtensio™ Ultimate, two DCBs (3.5×38 mm and 3.5×40 mm) were delivered to the proximal-to-mid RCA stenosis and inflated at low pressure.
Final Angiography
Angiography demonstrated excellent vessel expansion with TIMI flow grade 3.
Key Takeaways
When the CTO ostium is ambiguous and antegrade techniques stall, hydrodissection improves crossing efficiency and safety.
TrueVision™ IVUS confirmed true-lumen wire position after crossing and guided subsequent treatment.
TrueCross™ microcatheter provided sustained antegrade support for wire navigation, hydrodissection, and wire escalation, enabling successful recanalization.
Deep intubation of TrueExtensio™ Ultimate with self-anchoring capability established a stable platform in the distal RCA, improving drug-coated balloon deliverability and reducing drug loss.
For younger patients, a stent-free strategy shortens antiplatelet therapy and improves long-term quality of life and prognosis.