Treatment of a LAD CTO with the New CenterCross “Anchoring Catheter”

A 72-year-old female had an abnormal nuclear myocardial perfusion stress test and underwent diagnostic cardiac catheterization, which revealed a mid left anterior descending coronary artery (LAD) chronic total occlusion (CTO) secondary to in-stent restenosis (ISR) and a 70 to 80% stenosis in the diagonal branch, with the latter intervened upon at the time of the diagnostic procedure. The patient was referred to us for treatment of the mid LAD CTO. 

The patient was draped and prepped in a sterile fashion. Both common femoral arteries were accessed in the usual fashion with bilateral 8 French sheaths. Selective angiograms of both the right coronary artery (RCA) and left system (Figure 1) were done to assess the collateral network, with intracoronary nitroglycerin (NTG) administered. The distal LAD had left-to-left collaterals and minimal right collaterals were noted. The Japanese CTO score was a 2, with a blunt proximal cap occlusion and a length of about 30 to 35 mm. Previous angiograms were studied which revealed a patent stent approximately a year and half earlier just downstream from the distal edge of the stent. The diameter of the vessel was 2.5 mm. An XB (extra backup) 3.5 guide catheter (Cordis) was used to cannulate the left main, and for the RCA, a Judkins Right (JR) 4 guide catheter (Cordis) was used. A total of 10,000 units of intravenous heparin was given and activated clotting times (ACTs) were followed closely to maintain an ACT above 300 seconds.  

A CenterCross catheter (Roxwood Medical) (Figure 2) with a Micro14 microcatheter (Roxwood Medical) (Figure 3) were loaded onto a Fielder XT guide wire (Abbott Vascular) and brought to the level of the ISR, which began right at the bifurcation (Figure 4). The self-expanding nitinol scaffold of the CenterCross was deployed and provided excellent support, while steering the wire and equipment from going into the diagonal branch. Manipulation of the wire and microcatheter resulted in the lesion being crossed within 2 minutes (Figure 5). The Micro14 was advanced to the distal LAD and the Fielder XT was then removed to confirm angiographically that we were in the distal LAD. A Balance Middle Weight (BMW) .014-inch 300 mm guide wire was introduced, and the Micro14 and CenterCross were removed after re-sheathing the scaffold.  

Angioplasty was initiated with a 1.5 x 20 mm balloon, then a 2.0 x 30 mm balloon, with multiple balloon inflations. A 2.75 x 15 mm Cutting Balloon (Boston Scientific) was used within the stent, allowing a 2.5 x 28 mm drug-eluting stent to be deployed within the stent. Post dilatation was done with a 2.75 x 20 mm non-compliant balloon at high pressure. There was TIMI-3 flow, no thrombus formation, embolization or dissection was noted, and no extravasation (Figure 6). All equipment was removed and both common femorals were closed with a Perclose device (Abbott Vascular). 

This case had two failure predictors for a successful CTO percutaneous coronary intervention (PCI): a blunt occlusion and a large side branch. The CenterCross catheter provided excellent stabilization and support, allowing a quick penetration of the wire and microcatheter through the cap while staying in the true lumen. It was critical to stay within the stent as a wire traversed across the occlusion. The low profile of the Micro14 is ideal for tight, occlusive lesions to help gain distal vessel access. These tools have become a valuable part of our complex PCI armamentarium. 

Disclosures: Orlando Marrero reports he is a consultant for Boston Scientific. Dr. Eric Guerra reports no conflicts of interest regarding the content herein.

Orlando Marrero, RCIS, MBA, can be contacted at orlm8597@icloud.com. 

Dr. Eric Guerra can be contacted at at Hamilton Cardiology Associates, (706) 226-3434 or at ericguerra@yahoo.com.