Bail-Out Reverse Controlled Antegrade and Retrograde Subintimal Tracking

Accompanied by Multiple Complications in Coronary Chronic Total Occlusion

Author Affiliations: From the Division of Cardiology, Department of Medicine, SoonChunHyang University Bucheon Hospital, University of SoonChunHyang College of Medicine, Bucheon, Korea. The authors report no conflicts of interest regarding the content herein. Manuscript submitted May 29, 2008, provisional acceptance given August 28, 2008, and final version accepted September 5, 2008. Address for correspondence: Nae Hee Lee, MD, PhD, Division of Cardiology, SoonChunHyang University Bucheon Hospital, 1174 Jung-dong, Wonmi-gu, Bucheon-si, Gyeonggi-do, 420-767 Korea. E-mail: naeheelee@paran.com

_______________________________________________ ABSTRACT: Recently, a retrograde approach through collateral channels was introduced to improve the success rate of percutaneous coronary intervention (PCI) for a coronary chronic total occlusion (CTO). Among the various wire-crossing techniques via the retrograde approach, the reverse controlled antegrade and retrograde subintimal tracking (reverse CART) technique is the most rarely used due to technical difficulties and the probability of causing an iatrogenic dissection. We describe a case in which the conventional antegrade approach failed and the reverse CART technique was performed successfully in the setting of severe dissection, suggesting the usefulness of this novel technique. However, we encountered unexpected collateral-donor vessel complications that could have resulted in life-threatening ischemia, suggesting that a systemized approach by a highly-experienced operator is essential in ensuring the success of this complex procedure.

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J INVASIVE CARDIOL 2008;20:E334–E337 Percutaneous treatment of coronary chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. Due to remarkable developments in technology, the success rate for CTO intervention is on the rise.1,2 Among the various percutaneous coronary interventional (PCI) techniques for CTO, a retrograde approach through the collateral channels was recently proposed; this technique is believed to increase the success rate of PCI for CTO.3–5 Additionally, cases where the conventional antegrade approach cannot be used any longer in a grave situation, such as those involving a severe dissection or large hematomas, can be successfully treated using this technique.6 However, this technique carries the risk of potential collateral-donor coronary artery complications, which do not usually occur during the conventional antegrade approach for coronary CTO.4,7 Here, we present a case in which the retrograde approach using the reverse controlled antegrade and retrograde subintimal tracking (reverse CART) technique rescued a failed antegrade approach for coronary CTO. However, this novel approach was accompanied by unexpected complications of the collateral-donor coronary artery. Case Report. The patient was a 46-year-old male with exertional chest pain and dyspnea for 10 months. His coronary risk factors were diabetes mellitus, hypertension and smoking. His resting electrocardiogram was non-specific, and echocardiographic examination showed mild concentric left ventricular hypertrophy with a normal ejection fraction. A diagnostic coronary angiography revealed CTOs at the mid-left anterior descending artery (LAD) and proximal right coronary artery (RCA) (Figures 1A and B). We planned staged PCI and first attempted recanalization of the LAD-CTO, which was successfully treated with 3 Taxus® stents (Boston Scientific Corp., Natick, Massachusetts) from the mid-to- proximal LAD via the antegrade approach. We then tried to open the RCA-CTO 3 days later. A 7 Fr AL-2 guiding catheter (Cordis Corp., Miami Lakes, Florida) for the RCA and a 5 Fr JL-4 diagnostic catheter (Cordis) for the left coronary artery (LCA) were used via both femoral arteries for the conventional antegrade approach. However, extensive dissection occurred, which propagated to the distal RCA and compromised coronary flow distal to the CTO (Figure 1C). We carefully reviewed the collateral channels and found a tiny continuous septal connection between the mid-LAD and posterior descending artery (PDA), which could have made the retrograde approach possible. After a 90 cm 7 Fr XB 3.5 guiding catheter (Cordis) was engaged in the LCA, a Fielder wire (Asahi Intec, Tokyo, Japan) with the support of a Progreat microcatheter (Terumo Corp., Somerset, New Jersey) successfully negotiated the septal collateral and reached the distal CTO. After septal dilatation using a 1.25 x 15 mm Ryujin™ balloon (Terumo Medical Corp., Somerset, New Jersey) at low pressure (2 atm), we used Choice PT (Boston Scientific), Miracle 6g (Asahi Intec), and Conquest Pro wires (Asahi Intec) sequentially to directly cross the CTO (retrograde wire-crossing technique), but they repeatedly entered the subintimal space and failed to enter the proximal true lumen. After several unsuccessful attempts, we decided to perform the reverse CART technique. After the antegrade Choice PT wire was intentionally located at the subintimal space of the mid-RCA, antegrade ballooning using a 2.0 x 15 mm Ryujin balloon was performed several times (4 atm) at the CTO and the proximal RCA to create a large channel between the proximal true lumen and the subintimal space of the CTO (Figure 2A). Another retrograde Choice PT wire was then manipulated and advanced alongside the deflated antegrade balloon that lay across the subintimal space of the CTO and the proximal true lumen (Figure 2B). Eventually, the retrograde Choice PT wire was passed into the proximal true lumen. After the retrograde wire entered the right guiding catheter, it was anchored by antegrade ballooning in the guiding catheter to facilitate the retrograde balloon passage through the CTO (Figure 2C). Following several retrograde predilatations with a 1.5 mm and a 2.0 mm balloon, the retrograde wire was substituted with a 300 cm Flexiwire, which was advanced and guided outside the body through the opposite guiding catheter. Thereafter, using a double-lumen Crusade catheter (Kaneka Corp., Tokyo, Japan), another Flexiwire was antegradely delivered to the distal RCA, and an attempt was then made to remove the drawn-out retrograde Flexiwire. However, severe resistance developed and the left guiding catheter was pulled down to the mid-LAD segment, which provoked a distortion of the previous stent at the proximal LAD (Figure 3A). After bail-out stenting with a 3.5 x 16 mm Taxus stent, several antegrade predilatations were performed using a 2.5 x 20 mm and a 2.75 x 20 mm balloon and 3 Taxus stents (2.75 x 32 mm, 3.0 x 32 mm and 3.5 x 32 mm) were finally placed from the distal to proximal RCA with good result (Figure 3B). However, after stent deployment, acute thrombosis of the stented segment of the proximal LAD occurred (Figure 3C), which was urgently treated by an infusion of abciximab, suction of the thrombus with a 6 Fr Thrombuster (Kaneka Corp.), and, finally, ballooning with a 4.0 x 10 mm Kongou balloon (Terumo) at 16 atm, as intravascular ultrasound (IVUS) revealed stent underexpansion. After completing the procedure, the patient was stable and his peak CK-MB was 14.2 ng/mL. The patient was discharged 5 days after the procedure, and a 10-month follow-up angiogram showed no evidence of restenosis. Discussion. Among the different techniques in retrograde PCI for coronary CTO, the CART technique creates a connection between the subintimal space of the CTO lesion and the distal true lumen by retrograde ballooning from the distal true lumen to the subintimal space of the CTO lesion for antegrade passage of the wire.3 On the other hand, the reverse CART technique creates a connection between the subintimal space of the CTO lesion and the proximal true lumen by antegrade ballooning from the proximal true lumen to the subintimal space of the CTO lesion for retrograde passage of the wire.4 The reverse CART technique has potential disadvantages compared to the CART technique. First, manipulation of the retrograde wire is much more difficult than antegrade wire handling due to the long course and many angulations over the retrograde pathway. However, the more serious disadvantage of this technique is that subintimal ballooning in the antegrade direction can provoke severe iatrogenic dissection, which may propagate and compromise the true lumen distal to the CTO site. Thus, this technique is rarely used in retrograde PCI, and it may be reasonable to reserve this technique for cases where other retrograde techniques are unsuccessful. In this case, the bail-out retrograde approach via the reverse CART technique was successfully performed after a conventional antegrade attempt failed. We attempted a reverse CART technique soon after the retrograde wire-crossing technique failed. The reason for attempting this technique without trying the CART technique was that the possibility of successful antegrade wire passage from the subintimal space to the true lumen distal to the CTO seemed to be low, since the distal true lumen was already collapsed by extensive dissection and further antegrade wire handling could have aggravated the dissection. Although antegrade subintimal ballooning poses the possibility of aggravating the preexisting dissection, it could be prevented or lessened to some degree by avoidance of antegrade dye injection until deployment of the first stent, or by retrograde ballooning at the distal true lumen during antegrade subintimal ballooning. In this case, we experienced unexpected complications that usually do not occur with the conventional antegrade approach. The first complication was collateral-donor artery stent distortion caused by unexpected guiding catheter movement to the mid-LAD during removal of the retrograde wire. The tortuous collateral channel and inadequate dilatation of the septal collateral may cause kinking and entrapment of the guidewire, which can cause severe resistance, resulting in pulling of the guiding catheter into the deep portion of the donor artery during wire removal. Thus, avoidance of a severe tortuous collateral channel and sufficient dilatation of the septal channel are required to prevent such an unexpected situation. In this case, we employed the method described by Ozawa, in which the passed retrograde guidewire was guided outside the body through an opposite guiding catheter and the subsequent procedure was performed via this drawn-out wire.8 However, this method is cumbersome and time-consuming, with the chance of unexpected complications. Thus, it is reasonable to pass another guidewire antegradely once retrograde predilatation is successfully performed. Unless this maneuver is possible, instead of a support wire such as the Flexiwire, a thin soft wire such as the Rota floppy (Boston Scientific) should be used for a retrogradely drawn-out wire in order to decrease the friction between the wire and the collateral channel.4 To our knowledge, this successful procedure may be the first reported case in which the retrograde approach using the reverse CART technique rescued a failed conventional antegrade approach to treat a coronary CTO in the setting of extensive dissection. However, this technique may be accompanied by unexpected complications, among which collateral-donor artery injury can lead to fatal ischemic complications, suggesting that a systemized approach by a highly-experienced operator is essential to ensure the success of this procedure.

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