Successful CTO Recanalization with TrueExtensio™ Ultimate Balloon Extension Catheter

Introduction

In complex PCI, securing strong and stable guide support is often the prerequisite for successful device delivery, especially when facing severe tortuosity, calcification, and distal access challenges. Professor Wang Xiaoqun from Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, presents a case of extreme resistance. The patient presented with a tortuous and severely calcified RCA, where previous attempts were limited by poor device deliverability. Learning from prior experience, the operator utilized the TrueExtensio™ Ultimate balloon extension catheter early in the procedure. This strategy established a strong backup support system, facilitating microcatheter and subsequent device delivery, ultimately leading to the successful recanalization of the RCA CTO.

Patient Profile

• Sex/Age: Male, 83 years old

• Chief Complaint: Chest tightness and chest pain for 1 year

• History: The patient developed chest tightness with chest pain and precordial pain of no apparent cause 1 year prior. CAG + PCI was performed in November 2025; however, due to severe proximal RCA calcification, the procedure was terminated given patient tolerability and prolonged procedural time.

• Risk Factors: Hypertension, Diabetes.

Diagnostic Findings

• Biochemistry: HbA1c 6.66% ↑; Cystatin C 1.94 mg/L ↑; HDL-C 0.67 mmol/L ↓; ApoA1 0.86 g/L ↓

• Echocardiography: Left ventricular hypertrophy, regional wall motion abnormalities, dilated aortic sinus, degenerative aortic valve with mild-to-moderate regurgitation

• Diagnosis: Stable angina

November 2025 — Previous Procedure

• Attempts: A 6F SAL75 guiding catheter was used. Multiple guidewires (Fielder XTR, Fielder XT, Pilot 150, Gaia Second) were attempted. The Pilot 150 successfully crossed the lesion, confirmed to be in the true lumen via contralateral angiography.

• Challenges: Despite using a Guidezilla extension catheter, microcatheters (Instantpass, Finecross, Cosair pro) failed to cross the severe calcification. Predilation with 0.75×10mm and 1.0×6mm balloons met with significant resistance.

• Result: The guiding catheter was exchanged for another new 6F SAL 7.5, and the ULTIMATEbros 3 guidewire was advanced to cross the distal occlusion, then still failed to cross with CSW-135 penetration microcatheter. The procedure was terminated due to prolonged time and patient intolerance.

  
  

June 2026 — Pre-Procedural Angiography

• RCA: Proximal occlusion.

• LCA: No significant stenosis in the LM; LAD proximal 75% stenosis; D1 proximal 70% stenosis; LCX proximal 80% stenosis; OM1 proximal 70% stenosis; Distal LCX 85% stenosis.

June 2026 — Procedure Highlights

• Establishing Support: After engaging the right coronary ostium with a 7F SAL 1.0 guiding catheter, the TrueExtensio™ Ultimate balloon extension catheter was deployed, enabling the CSW-135 penetration microcatheter carrying a Pilot 200 guidewire to cross the RCA CTO lesion.

• Lesion Preparation: Following guidewire exchange and microcatheter withdrawal, predilatation was performed using 1.0 × 6 mm, 1.5 × 15 mm, and 2.0 × 20 mm balloons — all delivered with TrueExtensio™ Ultimate support.

• Plaque Modification: IVUS assessment (Insight Lifetech TRUEVISION) was then performed. Given suboptimal expansion of the RCA lesion with a 2.5 × 12 mm balloon, rotational atherectomy (RA) was initiated using a 1.25 mm burr, followed by intravascular lithotripsy (IVL) with a 3.0 mm balloon.

• Stenting: Three stents were implanted sequentially from distal to ostium: 3.0 × 38 mm, 3.5 × 38 mm, and 3.5 × 28 mm.

• Optimization: Post-dilation was performed using 2.5×12mm, 3.0×12mm, 3.5×15mm, and 4.0×12mm balloons.

  
  

Review angiography revealed residual stenosis; a 2.0 × 20 mm balloon was used to dilate the distal RCA, followed by a 2.0 × 20 mm drug-coated balloon (DCB) inflated for 1 minute.

• Final Result: Angiography showed good expansion with no dissection or hematoma. Distal TIMI flow grade 3 was achieved. The left coronary lesions were scheduled for staged treatment.

Key Takeaways

• Overcoming Extreme Resistance: For severely calcified, tortuous, and high-resistance CTO lesions where conventional extension catheters fail to advance, the TrueExtensio Ultimate utilizes a self-anchoring mechanism to establish robust guide support, enabling successful device crossing in challenging anatomy.

  
  

• Precision IVUS Guidance: Throughout the procedure, Insight Lifetech TRUEVISION IVUS provided critical intravascular imaging, guiding optimal device selection and informing the stent implantation strategy for precise lesion coverage.

  
  

• Synergistic Plaque Modification: The combined application of Rotational Atherectomy (RA) and Intravascular Lithotripsy (IVL) facilitated multi-level calcium modification, creating the necessary conditions for adequate balloon expansion and successful stent delivery.

  
  

• Procedural Optimization: In complex coronary interventions, procedural optimization is essential. This includes selecting stents with superior conformability and expansion performance, utilizing intravascular imaging for precise implantation, and performing adequate post-dilatation to minimize the risks of in-stent restenosis and thrombosis.