Figure 16: Breaking through the distal fibrous cap using the side wire technique
In this patient, the wire is restricted by heavy calcification throughout the RCA and by a sharp proximal bend. In addition to this, another bend in the distal portion of the CTO and diffuse plaque build-up meant I had to attempt to make my perforation by turning the wire towards the AM diagonal and trying to get at the distal fibrous cap from the AM ostium (a)(b). The problem was that the wire had gone slightly too far down into the AM diagonal (c). I therefore had to change to a rota-wire (d), and rotablate with a 1.25mm burr. I managed to position the burr in the ostium correctly and not too far, and avoid any distal vessel perforation (e). After rotablation, with the plaque at the AM branch excised (f), the wire advanced easily into the main trunk (g).