Complete Revascularization of Multiple Coronary CTOs in a Single Session Using Hydrodynamic Contrast Recanalization

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is technically more challenging than non-CTO PCI. The development of novel CTO-specific PCI techniques, such as hydrodynamic contrast recanalization (HDR), has led to improved technical success with low complication rates. We present a case of successful single-session PCI of multiple CTOs using HDR in an elderly patient. Our report highlights the feasibility and advantages of single-session complete revascularization in patients with multiple CTOs.

A 71-year-old woman with multiple comorbidities, including CAD, heart failure with reduced ejection fraction (HFrEF), chronic kidney disease stage 3 (CKD), and lung cancer in remission, was admitted with NYHA class IV symptoms. Coronary angiography revealed CTO of all three major coronary arteries. Given her high surgical risk and frailty, percutaneous revascularization was recommended by the Heart Team. The patient underwent successful HDR-facilitated CTO PCI of the left anterior descending (LAD), left circumflex (LCX), and right coronary arteries (RCA) in a single session. TIMI 3 flow was restored in all three vessels after successful drug-eluting stent (DES) placement. The patient's symptoms markedly improved postprocedure.

HDR is a novel CTO crossing technique that uses contrast modulation beyond the boundary of the proximal cap to facilitate the passage of polymer-jacketed wires. Reported advantages of HDR include a faster crossing time and side branch preservation. Using HDR, we recanalized multiple CTOs in an elderly patient in under 3 h, achieving single-session complete revascularization that improved clinical outcomes and minimized repeat procedural risks. This case highlights the potential role of HDR as a safe and efficient adjunct to conventional CTO PCI techniques in achieving optimal outcomes.