Case Report: Angiographic Remodeling of a Chronic Total Occlusion Four Years After Extraplaque Wiring: Implications for Procedural Reattempt

Abstract Background An investment procedure during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) involves intentional alteration of the proximal cap with the aim of facilitating subsequent CTO PCI. Extraplaque wiring may alter the CTO segment without modification of the proximal cap; however, whether such alterations meaningfully improve future CTO PCI success is uncertain. Case Summary A 71-year-old gentleman with a CTO of the second obtuse marginal and Canadian Cardiovascular Society (CCS) class III symptoms underwent an initial CTO PCI attempt that was aborted after extraplaque wiring without balloon dilation. Four years later, repeat angiography demonstrated shortening of the CTO segment. During reattempt, an initial polymer-jacketed wire tracked extraplaque, and successful crossing was achieved using parallel wiring, followed by stent implantation with restoration of TIMI 3 flow. Discussion Interval change was observed within the CTO segment years after prior extraplaque instrumentation. The mechanism underlying this change is uncertain and may reflect lesion evolution, extraplaque manipulation, or a combination of factors. Importantly, despite shortening of the occluded segment, this did not simplify crossing at reattempt, which remained technically complex. These findings suggest that shortening of the CTO segment alone should not be assumed to confer procedural advantage and highlight the need for further systematic evaluation of staged CTO strategies.