Complex recanalization of the proximal left anterior descending artery with dual radial access An interventional challenge, case report.

Abstract

Introduction: Chronic total coronary occlusions (CTOs) are an advanced form of atherosclerosis and are linked to a poor prognosis, especially when they involve large areas supplied by the anterior descending artery (AD). Prolonged loss of flow causes persistent myocardial ischemia, impaired left ventricular function, increased risk of malignant arrhythmias, and higher mortality. Successful recanalization restores blood flow, improves contractility, reduces major events, and enhances long-term survival.

Case presentation: A 68-year-old man with a history of hypertension presents with angina-like chest pain that rapidly progressed from stable to unstable, unrelieved by rest. The EKG shows an inactive electrical area with a pathological Q-wave on the anteroseptal side. The echocardiogram reveals a left ventricular ejection fraction (LVEF) of 45%, with notable hypokinesia in the anteroseptal and apical regions. Coronary angiography demonstrates a chronic total occlusion (CTO) in the proximal segment of the anterior descending artery (AD), with no antegrade flow.

Intervention: It was decided to perform recanalization using the anterograde approach supported by double radial access. Successful guidewire crossing into the true distal vessel was achieved. Predilation and sequential placement of two drug-eluting stents (DES) were performed, resulting in complete vessel recanalization and restoration of antegrade flow (TIMI III).

Discussion: Modern registries such as Euro CTO and OPEN CTO have shown that successful recanalization improves ventricular function, alleviates symptoms, and reduces major cardiovascular events—particularly when the occlusion involves the proximal AD, which supplies an extensive myocardial territory. The choice of the anterograde strategy with double radial access enabled more precise and safer planning by facilitating real-time visualization of both coronary systems and confirming the distal lumen position of the guidewire.