Ping-Pong Guide Catheter Technique for Facilitating Antegrade Crossing of a Chronic Total Occlusion

A 60-year-old man was referred for percutaneous coronary intervention of a proximal left circumflex (Cx) chronic total occlusion (CTO) with distal filling via epicardial collaterals from the left anterior descending (LAD) artery. The 30 mm lesion had a clearly defined proximal cap (Figure, A) with a bifurcation present at the distal cap (Figure, B).

An initial antegrade approach with wire escalation was the first option, followed by switching to antegrade dissection re-entry if there was no progress. Due to a short left main, we used 2 guide catheters sub selectively engaging the LAD and the Cx to minimize the risk of causing or extending a Cx dissection during antegrade crossing attempts. Using biradial access, we engaged the Cx with a 7 French (Fr) extra-backup (EBU) 3.0 guide catheter, and the LAD with a 6 Fr EBU 3.5 guide catheter (Figure, C). A Fielder XT guidewire (Asahi Intecc Medical) (Figure, D), supported by a microcatheter, crossed antegrade into the distal true lumen (Figure, E), but the microcatheter could not be advanced through the occlusion. A 1.0 mm x 15 mm Sapphire Pro balloon (OrbusNeich) successfully crossed and dilated the lesion with an excellent final result after stent implantation (Figure, F).

The ping-pong technique has been used in retrograde CTO interventions to facilitate guidewire externalization, and to minimize pericardial bleeding while delivering a covered stent in large vessel coronary perforations. In our case, the ping-pong technique was used for facilitating antegrade CTO crossing in a patient with ipsilateral collaterals: one catheter selectively engaged the circumflex for CTO crossing, whereas the other one selectively engaged the left main, allowing visualization of the distal true lumen without causing dissection and subintimal hematoma. Caution should be exercised with this technique to minimize the risk of pressure damping and ischemia, or injury of the donor vessel. 

Affiliations and Disclosures

From the ¹Athens Red Cross Hospital, Athens, Greece; ²Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA.

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

Address for correspondence: Ioannis Tsiafoutis, MD, PhD, 2 Athanasaki Street, 11526, Athens, Greece. Email: tsiafoutisg@yahoo.com