Applications of the Distal Anchoring Technique in Coronary and Peripheral Interventions

ABSTRACT: The distal balloon anchoring technique involves inflation of a balloon distal to or at a target lesion to facilitate equipment delivery. We report various applications of this technique to facilitate complex coronary and peripheral arterial interventions. 

J INVASIVE CARDIOL 2011;23:291–294

Key words: percutaneous coronary intervention, chronic total occlusion, stents

________________________________________

The balloon anchoring technique was initially described by Fujita in 2003 as inflation of a balloon in the sidebranch of a target coronary vessel to facilitate equipment delivery to a target lesion.¹ Two variations of this technique (coaxial and distal anchoring) have subsequently been described. In coaxial anchoring, a balloon is inflated proximally in the target coronary vessel to enhance the penetration capacity of a guidewire.² In distal anchoring, a balloon is inflated distal to or at the target lesion to enhance support for equipment delivery.² We present a series of challenging coronary and peripheral intervention cases, in which use of the distal balloon anchoring technique facilitated procedural success.

Case 1

An 85-year-old man presented with inferior ST-segment acute myocardial infarction. Emergency diagnostic angiography demonstrated distal occlusion (arrow, Figure 1A) of a tortuous and severely calcified right coronary artery (RCA). The RCA was engaged with a 6 French (Fr) JR4 guide and the lesion was wired with difficulty using a Whisper wire (Abbott Vascular, Santa Clara, California) and predilated with a 2.0 x 12 mm balloon (Figure 1B). We were unable to deliver a 3.0 x 12 mm everolimus-eluting stent (Abbott Vascular) (Figure 1C), in spite of using 2 buddy wires and performing multiple dilations of the lesion with 2.5 mm and 3.0 mm balloons. Due to calcification, we could not deep-seat the guide catheter using clockwise rotation . We subsequently inflated a 3.0 x 10 mm balloon at the lesion (distal anchor) and were then able to advance the guide catheter to the mid RCA (Figure 1D). No pressure dampening was observed. The 3.0 x 12 mm stent was easily delivered (Figure 1E) and deployed at the distal RCA lesion, restoring distal RCA patency (Figure 1F).

Case 2

A 76-year-old man with stable angina was referred for percutaneous coronary intervention (PCI) of a proximal RCA chronic total occlusion (CTO) (Figure 2A). We were unable to cross the CTO antegradely, but were able to retrogradely cross the lesion with a Pilot 200 wire (Abbott Vascular) through a Corsair catheter (Abbott Vascular) (arrow, Figure 2B). We were then able to advance an antegrade guidewire to the distal RCA, but were unable to advance even a 1.5 mm balloon through the CTO. We exchanged the Corsair for a 2.5 x 12 mm balloon that was advanced retrogradely to the distal RCA and was inflated (arrows, Figure 2C), trapping the antegrade guidewire (distal trap). We were then able to  antegradely deliver a 1.5 mm balloon to the lesion (Figure 2D), and successfully stent the lesion with five everolimus-eluting stents (Figure 2E).

Case 3

A 58-year-old woman with stable angina was referred for PCI of a proximal RCA CTO (Figure 3A). Due to the proximal location of the RCA occlusion and the presence of a large sidebranch at the proximal cap, a primary retrograde approach was utilized. The RCA CTO was crossed retrogradely with a Confianza Pro 12 wire (Abbott Vascular) advanced through a Corsair catheter (Figure 3B). The retrograde wire was snared into the antegrade guide catheter using a 12 x 20 mm Ensnare (Merit Medical Systems, Inc., South Jordan, Utah), but could not be externalized, as it slipped from the snare. The Corsair catheter was advanced into the antegrade guide catheter, yet attempts to advance a ViperWire Advance (CSI, St. Paul, Minnesota) through the Corsair catheter into the antegrade guide catheter were not successful due to guide disengagement. To stabilize the Corsair catheter, a 3.0 x 12 mm balloon was advanced into the antegrade guide catheter and was inflated next to the Corsair catheter (distal trap), stabilizing it (Figure 3C). We were then able to successfully advance the ViperWire through the antegrade guide catheter until it was externalized. The RCA was successfully stented antegradely over the externalized guidewire with an excellent final angiographic result (Figure 3D).

Case 4

A 63-year-old man presented with stable angina. Diagnostic coronary angiography demonstrated a distal RCA CTO (Figure 4A) and the patient was referred for PCI. The CTO was wired using a Fielder FC guidewire (Abbott Vascular) through a Finecross catheter (Terumo, Somerset, New Jersey). The Fielder FC wire was subsequently exchanged for an Asahi soft wire (Abbott Vascular). Distal stent delivery could not be achieved in spite of using multiple buddy wires, aggressive balloon predilatation and a 7 Fr Guideliner catheter (Vascular Solutions, Minneapolis, Minnesota; Figure 4B). A 2.5 x 12 mm balloon was inserted to the distal RCA lesion over a buddy wire and inflated (distal anchor), enabling delivery of a 2.5 x 28 mm everolimus-eluting stent (Figure 4C). The process was repeated three more times to enable delivery of three more stents, providing an excellent final angiographic result (Figure 4D).

Case 5

A 50-year-old man presented with left thigh and calf claudication. Diagnostic peripheral angiography demonstrated severe disease of the left superficial femoral artery and acute angulation of the distal aortic bifurcation (Figure 5A). We were unable to advance a 6 Fr, 45 cm sheath to the left external iliac artery (Figure 5B), in spite of using a stiff 0.035˝ guidewire (Supracore; Abbott Vascular). However, after inflation of a 4.0 x 30 mm balloon within the left superficial femoral artery lesion, a 45 cm long sheath was successfully advanced to the left common femoral artery (Figure 5C), enabling successful treatment of the superficial femoral artery lesion with balloon angioplasty and cryoplasty.

Discussion

Our case series demonstrates various applications of the distal balloon anchoring technique for enabling deep intubation of a guide catheter (case 1), stabilizing the antegrade (case 2) or retrograde (case 3) guidewire in CTO interventions, enabling stent delivery through challenging anatomy (case 4), and facilitating delivery of a femoral sheath to the contralateral femoral artery (case 5).

There are several techniques that can increase guide catheter support, such as deep guide catheter intubation, use of larger size or more supportive guide shape, using one or multiple buddy wires, using a guide catheter extension [such as the Heartrail catheter (Terumo), the Proxis catheter (St Jude, Minneapolis, Minnesota), and the Guideliner catheter (Vascular Solutions)], or using various anchoring techniques.^2,3

The anchoring techniques (Table 1) are important for increasing guide catheter support. Most of the published literature focuses on the sidebranch anchoring technique, in which a balloon is inflated in a sidebranch of the target vessel.^1,4–12 In the coaxial anchor technique, a balloon is inflated within the target coronary artery proximal to the lesion (usually a CTO), enhancing the guidewire penetration capacity.¹² In the distal anchor technique, a balloon is inflated within the target artery itself, not into a sidebranch.² In most cases, the balloon should be inflated within the target lesion to minimize the risk for target artery injury with inflations distal to the target lesion. However, inflation distal to the target lesion may be required in some cases to deliver a stent to the target lesions.

A step-by-step description of the distal anchoring technique for treating coronary lesions follows: First, a large diameter (at least 7 Fr) guide catheter should be used, to allow simultaneous handling of the anchoring balloon and the stent or other equipment to be delivered. At our institution, 8 Fr guiding catheters are used in most complex coronary interventions, because they provide extra support, but also because they facilitate performance of distal anchoring or other advanced PCI techniques. Second, two wires^8,15 are advanced distal to the target lesion to enable utilization of the trapping balloon and the equipment in need of delivery, usually a stent. Third, the trapping balloon and the stent in need of delivery are advanced to the tip of the guide catheter. This is important in order to prevent prolonged periods of ischemia between inflation of the distal trapping balloon and delivery of the stent. Fourth, the distal trapping balloon is advanced to the target lesion and inflated usually at 10–12 atm (although occasionally higher inflation pressures, e.g., > 20 atm, are required to enhance the support provided by the anchor balloon). Either a compliant or non-compliant balloon can be utilized, although compliant balloons are more deliverable through tortuous and calcified coronary artery segments. Fifth, the stent is advanced toward the target lesion. Once the stent reaches the distal anchor balloon, the distal balloon is deflated and withdrawn to allow stent delivery to the lesion, while keeping both wires in place (in a buddy-wire fashion). Occasionally, post-removal of the distal trapping balloon, the stent may fail to reach the target lesion, in which case the distal trap balloon can be advanced distal to the lesion and inflated again (usually at 10–12 atm or lower to minimize the risk for distal vessel injury) to facilitate stent delivery to the lesion. Sixth, the guidewire over which the distal trap balloon was advanced is removed (to prevent possible entrapment by the stent), followed by stent deployment, usually at high pressures. The process can be repeated if delivery of more stents is needed to entirely cover the lesion (Figure 4).

Several types of equipment can be delivered using distal anchoring, such as balloons, stents, microcatheters, guide catheter extensions, or arterial sheaths.^11,13,14 However, use of the distal trap technique has limitations. The most important limitation is injury at the site of distal balloon inflation.² This can be minimized by inflating the distal trap balloon within the target lesion that will subsequently be stented, as in cases 1, 2, 4, and 5. Also, distal anchoring requires delivery of a balloon to the lesion, but may occasionally be difficult in diffusely diseased and calcified vessels; if a balloon cannot be delivered, then the sidebranch anchor technique could be utilized.^1,4–12 As described above, large guide catheters (≥ 7 French) are needed.^11,13,14

In summary, the distal anchor technique is a simple and readily available technique that can facilitate equipment delivery through challenging anatomy in both coronary and peripheral interventions.

References

1. Fujita S, Tamai H, Kyo E, et al. New technique for superior guiding catheter support during advancement of a balloon in coronary angioplasty: The anchor technique. Catheter Cardiovasc Interv 2003;59:482–488.
2. Di Mario C, Ramasami N. Techniques to enhance guide catheter support. Catheter Cardiovasc Interv 2008;72:505–512.
3. Saeed B, Brilakis ES. Percutaneous coronary intervention in tortuous coronary arteries: Associated complications and strategies to improve success. J Interv Cardiol 2008;21:504–511.
4. Surmely JF, Tsuchikane E, Katoh O, et al. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: The CART technique. J Invasive Cardiol 2006;18:334–338.
5. Hirokami M, Saito S, Muto H. Anchoring technique to improve guiding catheter support in coronary angioplasty of chronic total occlusions. Catheter Cardiovasc Interv 2006;67:366–371.
6. Surmely JF, Katoh O, Tsuchikane E, et al. Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv 2007;69:826–832.
7. Kirtane AJ, Stone GW. The Anchor-Tornus technique: A novel approach to “uncrossable” chronic total occlusions. Catheter Cardiovasc Interv 2007;70:554–557.
8. Matsumi J, Saito S. Progress in the retrograde approach for chronic total coronary artery occlusion: A case with successful angioplasty using CART and reverse-anchoring techniques 3 years after failed PCI via a retrograde approach. Catheter Cardiovasc Interv 2008;71:810–814.
9. Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv 2008;71:8–19.
10. Rathore S, Katoh O, Matsuo H, et al. Retrograde percutaneous recanalization of chronic total occlusion of the coronary arteries: Procedural outcomes and predictors of success in contemporary practice. Circ Cardiovasc Interv 2009;2:124–132.
11. Lee NH, Suh J, Seo HS. Double anchoring balloon technique for recanalization of coronary chronic total occlusion by retrograde approach. Catheter Cardiovasc Interv 2009;73:791–794.
12. Fang HY, Wu CC, Wu CJ. Successful transradial antegrade coronary intervention of a rare right coronary artery high anterior downward takeoff anomalous chronic total occlusion by double-anchoring technique and retrograde guidance. Int Heart J 2009;50:531–538.
13. Mamas MA, Fath-Ordoubadi F, Fraser DG. Distal stent delivery with Guideliner catheter: First in man experience. Catheter Cardiovasc Interv 2010;76:102–111.
14. Fang HY, Wu CJ. Rolling filling defect? Int J Cardiovasc Imaging 2010;26:485–486.
15. Christ G, Glogar D. Successful recanalization of a chronic occluded left anterior descending coronary artery with a modification of the retrograde proximal true lumen puncture technique: The antegrade microcatheter probing technique. Catheter Cardiovasc Interv 2009;73:272–275.

________________________________________

From VA North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, Texas.
Dr. Mahmood reports no conflicts of interest related to the content herein. Dr. Banerjee reports speaker honoraria from St. Jude Medical, Medtronic, and Johnson & Johnson; research support from Boston Scientific and the Medicines Company. Dr. Brilakis reports speaker honoraria from St Jude Medical and Terumo; research support from Abbott Vascular and Infraredx; salary from Medtronic (spouse).
Manuscript submitted March 23, 2011, provisional acceptance given April 20, 2011, final version accepted April 28, 2011.    
Address for correspondence: Emmanouil S. Brilakis, MD, PhD, VA North Texas Health Care System, The University of Texas Southwestern Medical Center at Dallas, Division of Cardiology (111A), 4500 S. Lancaster Rd., Dallas, TX, 75216. Email: esbrilakis@yahoo.com