Successful CRT Reimplantation After Coronary Sinus Total Occlusion Using CTO Wire Escalation Techniques: A Case Report

Coronary sinus (CS) abnormalities represent a major technical challenge during cardiac resynchronization therapy (CRT) reimplantation following transvenous lead extraction. Complete CS occlusion may preclude left ventricular (LV) lead delivery and often necessitates alternative pacing strategies or surgical epicardial lead placement. We report a case of successful CRT reimplantation in a patient with complete CS occlusion encountered during a right-sided approach. The occlusion was crossed using a stepwise guidewire escalation strategy adapted from chronic total occlusion (CTO) percutaneous coronary intervention techniques, followed by sequential balloon venoplasty. Despite the occurrence of a long-segment CS dissection, the LV lead was successfully advanced and implanted with stable electrical parameters. This case illustrates that selected CS occlusions during CRT procedures may be managed percutaneously using contemporary interventional tools and techniques.