Use of a Thrombectomy Catheter for Contrast Injection: A Novel Technique for Preventing Extension of an Aortocoronary Dissection During the Retrograde Approach to a Chronic Total Occlusion

ABSTRACT: Percutaneous coronary intervention of a chronic total occlusion can be complicated by aortocoronary dissection. To prevent extension of the dissection, repeat contrast injections are discouraged; however, they are sometimes required to confirm optimal distal angiographic result. We describe use of a thrombectomy catheter for distal contrast injection in one such patient that allowed distal vessel visualization without propagating the aortocoronary dissection.

J INVASIVE CARDIOL 2014;26(5):E54-E55

Key words: thrombectomy catheter, aortocoronary dissection

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Case Report. A 65-year-old woman with medically refractory angina was referred for percutaneous coronary intervention (PCI) of a right coronary artery (RCA) chronic total occlusion (CTO) (Figure 1A). The right posterior descending artery (PDA) filled by collaterals from the left anterior descending (LAD) coronary artery (Figure 1B) including a CC2 collateral from the LAD to the PDA (Figure 1C). A prior antegrade CTO PCI attempt had failed; hence, a primary retrograde approach was planned.

Bilateral femoral arterial access was obtained with 8 Fr sheaths. The left main was engaged with an XB 3.5 guide and the RCA with an AL1 guide catheter. The CC2 septal collateral was easily crossed with a Sion guidewire (Asahi Intecc) through a Corsair microcatheter (Asahi Intecc) (Figure 1D). Antegrade dissection was performed using a knuckle wire (Figure 1E), followed by successful retrograde guidewire crossing into the proximal RCA using the reverse controlled antegrade and retrograde tracking and dissection (reverse CART) technique. A R350 guidewire (Vascular Solutions) was externalized, followed by balloon angioplasty and stent implantation (Figure 1F). Antegrade injections caused an aortocoronary dissection (Figure 1G). We attempted to use intravascular ultrasound (IVUS) to determine whether additional stent implantation was required distal to the deployed stents, but the rotational IVUS catheter could not reach that coronary segment. Attempts to use a GuideLiner guide extension (Vascular Solutions) resulted in expansion of the dissection. A 7 Fr Export thrombectomy catheter (Medtronic, Inc) was advanced to the distal RCA and contrast injection was performed, confirming excellent distal angiographic result without extending the aortocoronary dissection. The patient had an uneventful recovery and complete angina relief.

Discussion. Aortocoronary dissection is a rare, yet potentially serious complication of CTO PCI because if it extends into the contralateral coronary ostium or the descending aorta,¹ it may require emergency cardiac surgery for correction or can lead to death.^2-7 Aortocoronary dissection of the donor vessel during CTO PCI is an especially severe complication, as it can rapidly result in acute hemodynamic collapse and/or death and requires immediate percutaneous treatment.^7-9

Once aortocoronary dissection occurs, it is of paramount importance to abstain from additional contrast injections that could result in extension of the dissection. Moreover, an ostial stent should be placed to cover the coronary ostium, which can be confirmed using IVUS. IVUS can also be used to ensure adequate distal vessel recanalization, but did not reach the target distal vessel in our patient. In four published aortocoronary dissection cases in CTO PCI series, 3 patients were treated conservatively^3,4 and 1 patient was treated with covered stent implantation.⁵ We demonstrate a creative solution to confirming an adequate distal angiographic result by distal insertion of a thrombectomy catheter and localized contrast injection, which does not back flow into the proximal part of the dissected vessel and does not extend the dissection. A 7 Fr thrombectomy catheter was used in our case (since we were already using an 8 Fr guide catheter for CTO PCI); however, a smaller 6 Fr thrombectomy catheter and even a large-lumen microcatheter or over-the-wire balloon could also provide adequate visualization of the distal true lumen and could be easier to deliver through the previously deployed stents. Follow-up aortic imaging (with transesophageal echocardiography or computed tomography) may still be required to ensure resolution of the dissection.

References

1. Liao MT, Liu SC, Lee JK, Chiang FT, Wu CK. Aortocoronary dissection with extension to the suprarenal abdominal aorta: a rare complication after percutaneous coronary intervention. JACC Cardiovasc Interv. 2012;5(12):1292-1293.
2. Carstensen S, Ward MR. Iatrogenic aortocoronary dissection: the case for immediate aortoostial stenting. Heart Lung Circ. 2008;17(4):325-329.
3. 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(2):124-132.
4. Rathore S, Matsuo H, Terashima M, et al. Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008: impact of novel guidewire techniques. JACC Cardiovasc Interv. 2009;2(6):489-497.
5. Wu CJ, Fang HY, Cheng CI, et al. The safety and feasibility of bilateral radial approach in chronic total occlusion percutaneous coronary intervention. Int Heart J. 2011;52(3):131-138.
6. Abdou SM, Wu CJ. Treatment of aortocoronary dissection complicating anomalous origin right coronary artery and chronic total intervention with intravascular ultrasound guided stenting. Catheter Cardiovasc Interv. 2011;78(6):914-919.
7. Brilakis ES, ed. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. Waltham, MA: Elsevier; 2013.
8. Brilakis ES, Karmpaliotis D, Patel V, Banerjee S. Complications of chronic total occlusion angioplasty. Intervent Cardiol Clin. 2012;1:373-389.
9. Shorrock D, Michael TT, Patel V, et al. Frequency and outcomes of aortocoronary dissection during percutaneous coronary intervention of chronic total occlusions: a case series and systematic review of the literature. Catheter Cardiovasc Interv. 2013 Dec 11 (Epub ahead of print).

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From the ¹VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas, and ²Bon Secours Richmond Cardiology Associates, Mechanicsville, Virginia.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kaminsky reports consulting fees from Abbott Vascular and Boston Scientific; speaker’s bureau for Astra Zeneka. Dr Brilakis reports personal fees from St Jude Medical, personal fees from Terumo, personal fees from Boston Scientific, personal fees from Asahi, from Abbott Vascular,  during the conduct of the study; personal fees from Janssen, personal fees from Sanofi, grants from Guerbet, outside the submitted work; and spouse is an employee of Medtronic.

Manuscript submitted August 23, 2013, provisional acceptance given November 7, 2013, final version accepted November 11, 2013.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Dallas VA Medical Center (111A), 4500 South Lancaster Road 111A), Dallas, TX 75216. Email: esbrilakis@gmail.com