Cutting Balloon in Reverse CART Technique for Recanalization of Chronic Coronary Total Occlusion

ABSTRACT: Chronic coronary total occlusion (CTO) is still one of the last frontiers for myocardial revascularization by percutaneous coronary interventions (PCI). New devices (microcatheters, dedicated tools, guidewires), new techniques, and retrograde approach increase success rate of CTO-PCI. The reverse controlled anterograde and retrograde subintimal tracking (CART) technique can be an option to succeed. Sometimes the retrograde guidewire fails to cross the calcified proximal cap into the antegrade space, despite several standard balloon inflations. In our case, we describe the first case of CTO-PCI by the reverse CART technique using a cutting balloon to facilitate the retrograde connection with the antegrade space in case of failure with conventional balloon.

J INVASIVE CARDIOL 2014;26(8):E115-E116

Key words: chronic coronary total occlusion, reverse CART, cutting balloon

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Case Report. A 73-year-old man with diabetes and arterial hypertension was referred to our institution for class II angina. Coronary angiography demonstrated a chronic total occlusion (CTO) of the right coronary artery (RCA) in its middle segment (Figure 1A), some atheroma in the left coronary artery without stenosis, and the left anterior descending artery provided septal collaterals to the distal RCA (Figure 1B). A single photon-emission computed tomography revealed a large reversible ischemia in the inferior wall. Therefore, we decided to perform percutaneous coronary intervention (PCI) for the CTO of the RCA using a double radial approach access. The RCA was approached with a 6 Fr Amplatz Left 0.75 guiding catheter (Medtronic) and the left coronary artery with a 7 Fr Extra Back-Up 3.75 guiding catheter (Medtronic). Unfortunately, it was a failure to cross the obstruction of the RCA by antegrade approach with a Fielder XT guidewire (Abbott Vascular) and with Miracle 12 and Confianza Pro 12  stiff wires (Asahi Intecc) loaded into a 2.6 Fr, 150 cm Finecross microcatheter (Terumo Corporation). Consequently, retrograde approach through septal collaterals was successfully performed with a Sion guidewire (Asahi Intecc) and a 150 cm Finecross microcatheter. The distal fibrotic cap was crossed with a Fielder XT guidewire (Figure 2) and a Miracle 12 stiff wire was placed antegradely in the CTO segment. We then attempted to perform a reverse controlled antegrade and retrograde subintimal tracking (CART) technique,¹ using a 4.0 x 15 mm Hiryu balloon (Terumo Corporation). With this technique, we tried to create an antegrade proximal space by inflating in the proximal cap a non-compliant (NC) balloon sized to the reference diameter of the artery (Figure 3A) to facilitate a retrograde crossing with a stiff Miracle 12 guidewire. Despite several inflations of the NC balloon, we failed to advance the retrograde guidewire into the proximal antegrade space and the proximal true lumen. We thought it was due to high proximal fibrous secondary to the renal failure; thereafter, we repeated the same technique using a 3.5 x 10 mm cutting balloon (Boston Scientific) (Figure 3B) smaller than the reference diameter of the artery, inflated in the proximal cap, which allowed us to progress with the Confianza Pro 12 guidewire retrogradely, and the microcatheter into the antegrade true lumen then into the antegrade guiding catheter. Subsequently, the successful externalization of a 330 cm guidewire out of the antegrade guiding catheter allowed us to pass an antegrade balloon over the retrograde 330 cm guidewire, and the occluded RCA was then successfully predilated. We then successfully deployed 4 Xience V drug-eluting stents  (Abbott Vascular) (3.5 x 8 mm, 3.5 x 38 mm, 4 x 33 mm, 4 x 23 mm) in the RCA with a good angiographic result (Figure 4).

Discussion. CTO-PCI remains one of the most challenging chapters in interventional cardiology. Technical and procedural success rates and long-term outcomes have improved along with increased operator experience and skill, the availability of new specialized guidewires, microcatheters, and dedicated devices, as well as many sophisticated techniques for crossing occluded arteries and the widespread use of drug-eluting stents.^2,3 The reverse CART technique has been shown to be safe and feasible, with a high success rate when performed by highly experienced operators.¹ This technique consists of introducing a guidewire on the distal cap of a CTO and advancing a second guidewire antegradely. The retrograde wire is advanced into the CTO segment, close to the proximal cap. Then, a proximal space is created by inflating an antegrade balloon, sized to the reference diameter of the artery,⁴ in order to allow the retrograde wire to cross the occlusion and pass into the antegrade true lumen through a controlled limited proximal dissection. In our case, we could not initially achieve the reverse CART with a standard non-compliant balloon. We considered it to be due to the fibrotic and calcified nature of the CTO in the context of renal failure and we tried to create a limited subintimal dissection at the site of the CTO lesion by using a cutting balloon. In order to decrease the risk of vessel rupture or large dissection, we used a cutting balloon smaller than the reference diameter of the artery. We recommend the use of IVUS to measure the reference diameter of the artery and to determine the suitable size of a cutting balloon to be sure that we are using a cutting balloon smaller than the reference diameter of the coronary artery. Then, the technique will be safe enough to be used in many situations repeatedly.

To our knowledge, this is the first description of a reverse CART technique using a cutting balloon instead of a semicompliant or non-compliant balloon. This tool allowed us to create tiny incisions via its blades (atherotomes). This device limits subintimal dissection and allows the expansion of the target lesion with less pressure on the vessel wall, which may reduce trauma compared with a conventional angioplasty balloon sized to the reference diameter of the artery, since a smaller cutting balloon was used to decrease the risk of perforation.

In this case, we were able to demonstrate the feasibility of this modified reverse CART technique with cutting balloon in case of failure with conventional balloon in the angioplasty of CTO lesion with resistant calcified proximal cap, which can be safely performed by experienced practitioners without major complications.

As with the standard reverse CART technique, we think that there is some risk of unexpected expansion of subintimal dilatation antegradely beyond the CTO lesion caused by antegrade wiring through the subintima and/or antegrade balloon dilation.

References

1. Kimura M, Katoh O, Tsuchikane E, et al. The efficacy of a bilateral approach for treating lesions with chronic total occlusions the CART (controlled anterograde and retrograde subintimal tracking) registry. JACC Cardiovasc Interv. 2009;2(11):1135-1141.
2. Suero JA, Marso SP, Jones PG, et al. Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience. J Am Coll Cardiol. 2001;38(2):409-414.
3. De Felice F, Fiorilli R, Parma A, et al. 3-year clinical outcome of patients with chronic total occlusion treated with drug-eluting stents. JACC Cardiovasc Interv. 2009;2(12):1260-1265.
4. Sianos G, Barlis P, Di Mario C, et al. European experience with the retrograde approach for the recanalization of coronary artery chronic total occlusions. A report on behalf of the euroCTO club. EuroIntervention. 2008;4(1):84-92.

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From the Department of Cardiology, University Hospital of Rangueil, Toulouse, France, and Purpan Medical School, Toulouse, France.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted October 15, 2013, provisional acceptance given October 28, 2013, final version accepted November 22, 2013.

Address for correspondence: Nicolas Boudou, MD, Department of Cardiology, University Hospital of Rangueil, 1, Avenue du Professeur Jean Poulhès, TSA 50032, 31059 Toulouse Cedex 9, France. Email: boudou.n@chu-toulouse.fr