Parallel Wire Technique as a Bailout for Chronic Total Occlusion Recanalization Due to Microcatheter Over-Torquing and Entrapment

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J INVASIVE CARDIOL 2025. doi:10.25270/jic/24.00362. Epub January 13, 2025.

Microcatheters are an indispensable tool for percutaneous coronary intervention (PCI) of chronic total occlusions (CTO), and they have multiple uses for the recanalization of this type of lesion. However, improper use can lead to serious complications during the procedure. Here, we show an example of microcatheter over-torquing, causing entrapment of the guidewire during recanalization of a CTO.

A 76-year-old man who underwent PCI of his left anterior descending artery and right coronary artery (RCA) 3 years ago was evaluated secondary to functional class deterioration due to dyspnea and angina. Diagnostic angiography showed an in-stent CTO of the RCA. It was decided to perform RCA-CTO coronary intervention (Figure 1A, Video 1).

We first advanced a 0.75 AL catheter through the femoral sheaths. Next, we advanced a Mamba Flex microcatheter (Boston Scientific) and performed antegrade wire escalation with Miracle 3 and 6 guidewires (Asahi) (Figure 1B). We managed to cross the proximal and distal cap and advanced the microcatheter to perform the guidewire exchange (Figure 1C, Video 2). However, due to over-torquing, the microcatheter became twisted on the guidewire (Figure 2A, Video 3). As a result, when trying to remove the guidewire or the microcatheter, we encountered resistance. Therefore, we could not remove either the guidewire or the balloon in isolation.

As a rescue maneuver, we advanced a second Miracle 6 guidewire and a Mamba Flex microcatheter in parallel (Figures 2B and C, Video 4), using the guidewire and the trapped microcatheter as a reference. In the same manner, we managed to cross the lesion and bring the guidewire to the distal segment of the posterior descending artery. With the second guidewire in the distal location, we decided to remove the guidewire and the trapped microcatheter (Figure 3A) using the Miracle guidewire as a partial workhorse.

We performed predilatation sequentially with 1.25 x 15-mm, 1.5 x 15-mm, and 2.5 x 20-mm balloons. Upon angiographic control, we observed adequate luminal gain. So, we advanced a Sion blue guidewire (Asahi) as a workhorse guidewire and removed the Miracle guidewire (Video 5). Upon intravascular ultrasound (IVUS), we observed restenosis resulting from stent underexpansion, with a distal stent diameter of 2.8 mm and a proximal stent diameter of 3.5 mm. We decided to place a second stent layer using long stents to minimize 3-layer territories in the junction areas. We advanced a 2.75 x 38-mm distal Synergy stent (Boston Scientific) and a 3.0 x 48-mm proximal Synergy stent (Figure 3B); then, we optimized the middle segment with a noncompliant (NC) Accuforce 3.0 x 15-mm balloon (Terumo) and the proximal segment with an NC Accuforce 3.5 x 15-mm balloon. We performed a second IVUS review and observed adequate expansion of both stents. The final angiographic control showed Thrombosis in Myocardial Infarction-3 flow, with no evidence of dissection (Figure 3C).

Over-rotation of microcatheters should be avoided as it can cause catheter deformation, entrapment, or fracture proximal to the catheter tip. When operators feel resistance to removing the microcatheter, they should first think about over-torquing and entrapment of the microcatheter. In these cases, one way to solve the problem is to advance a second guidewire without removing the previous so it can serve as a reference.

Affiliations and Disclosures

Marco A. Alcántara-Meléndez, MD; Antonio Vargas-Cruz, MD; César L. González-Aguilar, MD; Faustino J. Silva-Centeno, MD; Jesus González-Jasso, MD; Leonel Avendaño-Perez, MD; Rafael Esparza-Corona, MD; Heberto Aquino-Bruno, MD

From the Interventional Cardiology Service, Centro Médico Nacional 20 de Noviembre, Mexico City, Mexico.

Acknowledgments: The authors would like to thank to the hemodynamics team.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and to the publication of their data.

Address for correspondence: Heberto Aquino-Bruno, MD, 1421 Roberto Gayol St., del Valle, Mexico City 03100, Mexico. Email: hebert.ab07@gmail.com; X: @HA_Bruno07