Abstract 4119169: Navigating Complexity: The Carlino Technique in Multivessel Percutaneous Coronary Intervention for Chronic Total Occlusion

Introduction: Since the advent of percutaneous coronary intervention (PCI), the scope of this therapeutic intervention has broadened to include cases of life-threatening multivessel coronary artery disease that previously may have only been corrected surgically. PCI has become a common treatment of chronic total occlusion, and techniques continue to be developed to tackle more challenging cases. We present a complex case of NSTEMI with multi-vessel coronary artery disease treated with PCI via the Carlino technique. Case Description: A 60-year-old female with a history of hypertension, diabetes mellitus, and ischemic heart disease presented with severe chest pain that radiated to the neck and was associated with nausea and vomiting. Her EKG showed marked left-axis deviation, ST depressions in V2-V4, and RBBB. She was diagnosed with NSTEMI with a thrombolysis in myocardial infarction (TIMI) score of 5. She was loaded with aspirin and clopidogrel and was taken for left heart catheterization (LHC), which demonstrated three-vessel coronary artery disease with chronic 100% occlusion of the proximal left anterior descending artery, ostial 60-70% stenosis, and proximal 90-95% diseased left circumflex artery, while her right coronary artery had proximal 20-30% obstruction and mid 50-60% with right to left filling. The patient was advised CABG by the heart team, but the patient refused, and PCI was attempted on a shared decision basis. PCI was successful with the use of the Carlino technique: 0.5 ml of contrast dye was injected through a microcatheter to hydraulically recanalise the occlusion. The patient showed dramatic improvement and was discharged home on oral medications. Discussion: Treating multi-vessel coronary artery disease and CTO is challenging. PCI, particularly with the Carlino technique, offers a reliable approach. This technique, a modification of contrast-guided STAR, involves gentle contrast injection via microcatheter to modify plaque compliance and provide topographic information with regards to equipment location within vasculature, enhancing procedural success, especially in cases with impenetrable caps or calcified areas. Conclusion: This case is an example of how adaptive PCI techniques, such as the Carlino technique, can be employed to tackle complex instances of MvCAD that previously may have only been surgically corrected.