Dissection Re-entry Technique: How is it Really Looking?

J INVASIVE CARDIOL 2019;31(4):E58-E59.

Key words: chronic total occlusion, control and re-entry technique, dissection

A 65-year-old patient with a significant stenosis of the mid left anterior descending (LAD) coronary artery was referred to our cath lab for percutaneous coronary intervention (PCI) with rotational atherectomy, after a failed initial PCI attempt in a peripheral hospital, in which this heavily calcified mid LAD lesion proved to be balloon-undilatable (Figure 1A).

In our cath lab, upon initial angiographic assessment, we discovered that the vessel was totally occluded. The occluded lesion was approached with antegrade wire escalation using sequentially an Asahi Fielder XT wire, an Abbott Hi-Torque Pilot 200 wire, and finally an Asahi Confianza/Conquest Pro 12 wire. During the attempt, the vessel was dissected, and we therefore tried the subintimal tracking and re-entry technique, attempting wire-based re-entry to get into the true lumen. Unfortunately, this resulted in dissection enlargement and hematoma propagation in the distal vessel (Figures 1B and 1C; Video 1), even though we repeatedly aspirated the intramural hematoma.

Despite our best efforts, the patient was referred to surgery to have the LAD grafted. The surgeon took some impressive pictures of the severely dissected vessel (Figures 2A-2C) before he went on to repair and graft it with the left internal mammary artery. Surgical inspection demonstrated that the large hematoma compressed the lumen and thus eliminated the possibility of re-entry.  

Dissection re-entry is a well-known and widely used technique in all chronic total occlusion centers like ours. We herein provide an account of a failed re-entry attempt and provide in vivo photographic evidence of how the vessel looked after such an attempt. Keeping this evidence in mind, we should be more skeptical about dissection re-entry. The main learning points are: (1) keep dissection of subintimal space and hematoma limited; and (2) the use of dedicated materials and techniques for controlled re-entry should be encouraged.

From ¹Athens Red Cross Hospital, Athens, Greece; ²General Hospital of Kalamata; Kalamata, Greece; and ³Henry Dunant Hospital, Athens, Greece.

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.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 25, 2018.

Address for correspondence: Theodoros Zografos, MD, MSc, PhD, Consultant Cardiologist, 3rd Department of Cardiology, Hygeia Hospital Research Associate, Athens Red Cross Hospital, 8 Artemidos Street, 16672, Vari, Athens, Greece. Email: theodoroszografos@gmail.com