Jeffrey M. Chua, MD

Directions

Jeffrey M. Chua, MD ❤️ Healthy Heart. High success rates. Patient-focused.

Healthy Life
Your heart deserves the best care — & latest treatments

Specialist in:
✔️ Advanced Angioplasty
✔️ Complex PCI & CTO Procedures
✔️ Intravascular Imaging - IVUS, OCT

🩺 Cutting-edge care.

16/10/2026

When the heart has just stopped, how far should we go to save it?

A 79 y/o woman, admitted for ACS-NSTEMI, suffered a cardiac arrest just hours after admission. She was successfully resuscitated, but the battle was far from over.

Coronary angiography revealed severe multivessel CAD, including a long, heavily calcified LM-LAD lesion and an RCA CTO.

In a patient who has just survived cardiac arrest, the decision to undertake complex PCI is never an easy one. The patient is vulnerable. The physiological reserve is uncertain. The procedural risks are substantial. And the margin for error may be dangerously narrow.

It is precisely in these situations that even experienced operators may hesitate. But hesitation must be balanced against the consequences of leaving critical coronary disease untreated.

After careful consideration, we proceeded with complex multivessel PCI.

* RCA CTO — Successfully recanalized first through a straightforward antegrade approach.
* Severely calcified LM-LAD — Subsequently treated with rotational atherectomy to achieve adequate lesion modification and facilitate revascularization.

Both vessels were successfully recanalized.

But perhaps the most rewarding part of this case was not what happened inside the cath lab. The patient made a remarkable recovery. She regained consciousness, was successfully weaned off hemodynamic and ventilatory support, participated in cardiac rehabilitation, and was eventually discharged from the hospital.

From cardiac arrest and life support to recovery, rehabilitation, and finally going home.

This is what makes all the difficult decisions, calculated risks, and technical challenges worthwhile.

Sometimes, the patients who make us hesitate the most are the very ones for whom a carefully executed intervention may matter the most.

13/10/2026

Complex LM Trifurcation with Ostial LAD CTO — When Every Branch Matters

A 58-year-old man admitted for ACS-NSTEMI was found to have severe 3-vessel CAD, including a complex LM trifurcation lesion, an ostial LAD CTO with an ambiguous proximal cap, and a retroflexed LCX.

CABG was recommended but declined by the patient, prompting a complex PCI strategy.

The major challenge was not simply opening the CTO, but navigating the complex LM trifurcation while preserving access to and protecting its major branches.

Key procedural challenges:
1. Complex LM trifurcation anatomy with a retroflexed LCX
2. Ostial LAD CTO with an ambiguous proximal cap
3. Difficult CTO crossing while maintaining access to critical side branches
4. High risk of branch compromise during LM trifurcation reconstruction

Strategies employed:
* Primary antegrade CTO approach
* Internal plaque crushing (Open Sesame technique) to modify the resistant proximal cap
* HDR
* Antegrade wire escalation to achieve successful CTO crossing
* Hybrid treatment of the LM trifurcation to optimize revascularization while preserving major branches

The key to success was not any single technique, but the strategic combination of multiple techniques to overcome successive anatomical challenges.

02/10/2026

When the Previous Investment Procedure Changes the CTO Strategy

A 90-year-old woman with an LAD CTO underwent successful PCI using a primary ipsilateral retrograde approach through an epicardial collateral from the LCX.

Three years earlier, an antegrade CTO attempt resulted in guidewire passage through a long extraplaque course. The procedure was then stopped after subintimal plaque modification (SPM) was performed to serve as an investment strategy.

Her ischemic symptoms initially improved, but severe symptoms eventually recurred over the succeeding years and persisted despite optimal medical therapy. After further discussion with the patient and family, another PCI attempt was undertaken.

Baseline angiography demonstrated:
• Severe, heavily calcified ostial left main and LAD disease
• A long patent proximal subintimal tract created during the previous procedure
• Persistent total occlusion at the mid LAD

Key challenges and strategic questions

1. Severe calcified LM–LAD disease potentially requiring complex lesion preparation
2. LAD CTO with a long pre-existing proximal subintimal tract
3. Should another antegrade attempt be made, with distal true-lumen reentry from the established subintimal space?
4. Or would a primary retrograde strategy provide a more controlled path toward true-lumen reconstruction?

Strategy performed:

• Primary ipsilateral retrograde approach through an LCX-to-LAD epicardial collateral
• Direct retrograde intraplaque wiring of the CTO segment
• Reverse CART to overcome difficult proximal true-lumen reentry

This case highlights how a previous investment procedure can substantially alter the anatomy, and therefore the strategy of a subsequent CTO PCI.

Sometimes the most important question is not simply how to cross the CTO, but which direction offers the most controlled route back to true lumen.

22/09/2026

An elderly patient with heart failure and severe 3-vessel CAD with heavily calcified LM–LAD disease and CTO of the RCA.

Beyond the anatomy, the real challenge was deciding on the overall revascularization strategy.

Key questions before PCI:

• Which vessel should be treated first?
• Is complete revascularization necessary, or can an acceptable degree of incomplete revascularization be achieved?
• Should treatment be performed in one session or staged?
• Is mechanical circulatory support warranted?
• What calcium-modification strategy would provide the safest and most effective lesion preparation?

The procedure was performed under IABP support.

The RCA CTO was addressed first and successfully recanalized through a straightforward antegrade approach. A balloon-uncrossable segment required rotational atherectomy, followed by hybrid treatment with DES and DCB.

Patient was doing well after RCA intervention. Attention was then shifted to the heavily calcified left main–LAD disease. Sequential and progressive lesion preparation was performed, with IVL added for persistent balloon-undilatable segments, followed by successful DES implantation.

The LCX was intentionally left untreated after weighing the expected procedural benefit against the additional complexity and risk.

In CHIP PCI, success is not simply about treating every angiographic lesion. It is about deciding which lesions matter most, determining how much revascularization is enough, choosing the appropriate sequence and support strategy, and knowing when the procedural objective has already been achieved.

21/09/2026

Post-CABG RCA CTO — Treat the Vein Graft or Reconstruct the Native Vessel?

A post-CABG patient presented with a subtotally occluded SVG to the RCA, raising an important strategic question:

Do we take the easier route and intervene on the diseased vein graft, or pursue the more challenging native RCA CTO?

Given the long-term limitations and potential complications associated with SVG PCI, the decision was made to reconstruct the native RCA.

Successful recanalization was achieved through an antegrade CTO PCI strategy, using:

* Wire escalation
* Sequential HDR

The final native-vessel angiogram demonstrated a good PCI result with excellent distal runoff and almost no meaningful competitive flow from the vein graft. Then repeat graft angiography after native RCA reconstruction showed markedly sluggish distal SVG flow.

This raised another important question:

Once the native RCA has been successfully reconstructed and competitive graft flow is essentially absent, should the diseased SVG simply be left alone—or is there ever a role for intentional graft occlusion to reduce the potential risk of future native-vessel stent failure?

02/09/2026

UNCHARTED TERRITORY — Beyond the Coronaries

A challenging long, heavily calcified SFA CTO successfully recanalized through an unconventional retrograde approach via collateral crossing from the profunda femoris artery.

A different vascular territory—but many of the challenges felt remarkably familiar.

Key challenges:
• Long-segment SFA occlusion
• Heavily calcified, microcatheter-uncrossable distal CTO segment
• Difficult antegrade crossing with repeated extraplaque wire migration
• Difficult posterior tibial artery entry, limiting conventional retrograde access
• Difficult antegrade distal marker wiring
• Challenging reverse CART, as failure of the retrograde microcatheter to cross the distal CTO significantly reduced retrograde wire pe*******on, torque response, and control during attempts to establish the connection

Key strategies:
• Retrograde collateral crossing from the profunda femoris artery
• Multiple HDR attempts to facilitate intimal and intraplaque tracking—although the contrast staining patterns looked markedly different and unfamiliar compared with what we usually encounter in coronary CTO PCI
• Retrograde knuckle wiring to facilitate antegrade distal marker wiring
• CART technique to ultimately establish the connection and achieve successful recanalization

Different anatomy. Different vessel. Familiar CTO mindset.

A memorable first venture into a very different kind of CTO intervention.

24/08/2026

Simple-Looking CTO, Unexpected Complexity — A CHIP Case in Multivessel Disease

A seemingly straightforward RCA CTO combined with complex LM bifurcation disease turned into a technically demanding CHIP procedure—another reminder that angiographic appearance does not always predict procedural complexity.

Key challenges during RCA CTO PCI:

* Difficult RCA cannulation requiring multiple guide catheter attempts
* Balloon-uncrossable CTO despite successful wire crossing
* Severely resistant disease distal to the CTO, which proved both balloon- and RotaWire-uncrossable
* Difficult equipment delivery requiring multiple guide support and guide-extension strategies

Strategies employed:

* Multiple guide catheter configurations to achieve adequate RCA engagement and support
* Rotational atherectomy to facilitate balloon crossing of the CTO segment
* Multiple guide-extension catheter advancement techniques to improve device delivery across the resistant lesions
* Persistent escalation and modification of strategy as each new mechanical barrier was encountered

The complex LM bifurcation disease was subsequently treated using a hybrid DES + DCB strategy, allowing revascularization while limiting unnecessary additional metal at the bifurcation.

A complex case that looked relatively straightforward ultimately became a lesson in anticipating the unexpected, troubleshooting equipment-uncrossable lesions, and adapting strategy throughout the procedure.

21/08/2026

Double CTO, Staged Strategy — Knowing what to treat first, and when to stop

A challenging 2-vessel CTO involving both the LAD and RCA, successfully recanalized through a staged CTO PCI strategy one month apart.

Beyond the technical difficulty of two complex occlusions, this case emphasized several important aspects of CTO PCI: which vessel to treat first, how far to pursue an unsuccessful strategy, when to stop, and how the first procedure can help create the conditions for success at the next.

Key challenges:

* Double CTO involving the LAD and RCA — which vessel should be treated first?
* LAD CTO with an ambiguous proximal cap, small distal vessel with a bifurcation at the distal cap, and initially no suitable interventional collaterals
* RCA CTO with poorly visualized distal collateral filling
* Extremely challenging LAD crossing attempts despite multiple strategies, including 3D wiring, parallel wiring, and repeated retrograde attempts through different collateral channels
* Most importantly, recognizing when continued attempts were unlikely to provide additional benefit and when it was safer to stop and stage the procedure

Strategy and outcome:

Stage 1 — RCA CTO
Successfully recanalized using antegrade wire escalation with Sasuke-facilitated parallel wiring.

Rather than continuing increasingly difficult attempts at the LAD during the same session, the decision was made to stop and allow the patient to recover.

Stage 2 — LAD CTO, one month later
The LAD was revisited as a dedicated CTO procedure and successfully recanalized through a primary retrograde approach via septal collateral crossing.

This case was a reminder that complex CTO PCI is not simply about crossing every occlusion in a single sitting. Sometimes the most important procedural decision is knowing which vessel to treat first, when to change strategy, and when to stop.

A staged approach is not a failure to complete the procedure—it can be an integral part of the strategy that ultimately makes complete revascularization possible.

Address

Ortigas Avenue
Pasig
1800

Opening Hours

Monday 12pm - 4pm
Wednesday 12pm - 4pm
Friday 12pm - 4pm

Website

Alerts

Be the first to know and let us send you an email when Jeffrey M. Chua, MD posts news and promotions. Your email address will not be used for any other purpose, and you can unsubscribe at any time.

Shortcuts

Share

Category