Transradial Revascularization of an Ostial Left Main Chronic Total Occlusion

Case report

A 62-year-old female came to us with complaint of angina on exertion. Her past medical history included hypertension, dyslipidemia, and multivessel coronary artery disease, along with a severe left main (LM) stenosis. She was treated with coronary artery bypass graft surgery (CABG) nine months prior. Her CABG surgery was complicated by dissection of the ascending aorta, treated with a prosthetic graft. After the CABG, the patient continued to have angina on exertion and was being treated with optimal medical management, including ranolazine (Ranexa, Gilead Sciences).

A diagnostic cardiac catheterization was performed via the femoral approach, because of the unavailability of the surgical details of the ascending aorta repair and graft position. It was extremely difficult to cannulate the LM and a subselective angio showed an ostial-proximal chronic total occlusion (CTO) of the LM (Figure 1). The dominant right coronary artery (RCA) had a long area of severe stenosis in the distal artery. An aortogram showed the aortic prosthetic graft and no venous bypass grafts were seen (Figure 2).

The aortogram also showed tortuosity of the brachiocephalic artery (Figure 2). The left internal mammary artery (LIMA) to left anterior descending (LAD) was widely patent. The LIMA also perfused the circumflex artery (LCX) by retrograde flow, although it was limited because of the severe proximal LAD stenosis and severe ostial LCX stenosis (Figure 3A-B). 

The RCA was treated successfully with a long drug-eluting stent. The procedure was complicated by a 6 cm femoral hematoma requiring blood transfusion. Even after the RCA intervention, the patient continued to have same angina on exertion, and it continued to be disabling. Stress Myoview imaging was performed at this point, and showed anterolateral ischemia. We decided to intervene on the CTO of the ostial LM. Radial access was chosen despite the understanding of severe tortuosity of the subclavian for two reasons: 1) It is our preferred method of choice in most cases; 2) The bleeding complication during the last procedure.

A 6 French JL 3.5 guide was inserted via the right radial approach. It was extremely difficult to cannulate the LM with the guide catheter. Once the guide was facing the ostial LM, a Kinetix 0.014” wire (Boston Scientific) was inserted in the LM against resistance. With the obvious tactile feeling that the wire was subintimal, it was used to stabilize the guide in the ostial LM position.

Subsequently, a Confianza 0.014” wire (Abbott Vascular) with a 1.25 mm x 6 mm Sprinter over-the-wire balloon (Medtronic) was used to cross through the LM CTO (Figure 4). Distal injection was performed through the balloon to confirm the intraluminal position. A sequential incremental percutaneous transluminal coronary angioplasty was performed with 1.5, 2.0, and 3.0 mm balloons. The mid LCX lesion was treated with a 2.75 mm x 18 mm Promus drug-eluting stent (Boston Scientific). A 3.0 mm x 22 mm Promus stent was deployed from the aorto-ostial position to the proximal LCX (Figure 5). An 4.0 x 14 mm ostial Flash balloon (Ostial Corporation) was used to post-dilate and flare the aorto-ostial stent (Figure 5). Intravascular ultrasound confirmed perfect apposition of the stent and the final angiographic result can be seen in Figure 6. Two months later, the patient has completed cardiac rehabilitation and she remains free of angina. 

Discussion

Because of the safety and lower incidence of access-related complications in comparison to femoral access, the radial artery is commonly used for cardiac catheterization.^1,2 The radial approach also reduces vascular complications and offers improved mortality in the setting of ST-elevation myocardial infarction.^3,4

CTO revascularization is generally challenging, but even more so in an aorto-ostial location. This is mainly because of an inability to place the guide catheter selectively in the coronary artery. Furthermore, there is poor guide support to aid in crossing the wire through a CTO. Even after engaging the wire into the CTO, wire advancement pushes the guide out and catheter position can be lost. 

We present this case, performed via transradial approach, where active guide support was obtained by a unique technique. A 0.014” wire was tactfully advanced, despite the fact that it was entering the subintimal plane, by only pushing the wire to the extent that the catheter did not lose position. This fixed the guide in front of the origin of the LM. A second hydrophilic CTO wire was then used with an over-the-wire balloon support. Despite awareness of the need for solid support, we could only use a JL curve, because of the lack of the LM ostia to insert a guide. A 6 French guide catheter was used. The left radial was also prepped in case of the need to inject the LIMA to provide a contralateral injection. The challenge of aorto-ostial stent placement was eased with the Flash ostial balloon. Enabled by a novel dual balloon design, the distal balloon of the Flash system provides stability within the body of the stent for added control during dilatation at the ostium. 

The following tips may be helpful for use of the radial approach for PCI of a CTO lesion: 

• Avoid ad hoc intervention of a CTO. Always confirm viability and need, then plan the procedure.
• Active placement of the guide catheter to get maximum support is extremely important. We generally use an EBU curve for the left and a MAC 3.0 (Medtronic) or Amplatz left curve for the RCA. 
• Other options to obtain or enhance greater guide support include: 
• Use of a GuideLiner catheter (Vascular Solutions); 
• Use of an anchor balloon technique in a side branch; or 
• Very careful deep selective intubation of the guide catheter.
• Use of a long CTO wire (operator’s choice) with an over-the-wire balloon or crossing catheter is recommended for further support and for distal injection when needed. A short length balloon is preferred. 
• Dual access and visualization of collaterals is helpful when available.
• Use of right radial approach and keeping the wrist position very close to the side of the groin will reduce radiation exposure. 

Dr. Kintur Sanghvi can be contacted at SanghviK@Deborah.org.

Disclosure: Dr. Sanghvi reports no conflicts of interest regarding the content herein.

References

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2. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, Rigattieri S, Turri M, Anselmi M, Vassanelli C, Zardini P, Louvard Y, Hamon M. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004; 44: 349-356.
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