Retrograde Stent Target Technique for Left Main Chronic Total Occlusion Revascularization

Left main coronary artery chronic total occlusion (LM CTO) is challenging to manage, especially when grafts to the left anterior descending artery are down. LM CTO percutaneous intervention (PCI) represented 0.45% of all CTOs performed in the PROGRESS CTO registry with a success rate of 85% and a complication rate of 20%.¹

A 72-year-old woman presented with progressive angina and anterior ischemia on a nuclear stress test. She had a history of previous bypass graft surgery with an atretic left internal mammary artery graft (LIMA) to the left anterior descending artery (LAD) and patent vein grafts to the right coronary artery (RCA) and the obtuse marginal branch (OM). The left main coronary artery (LM) was heavily calcified and chronically occluded, and the distal LM was severely calcified (Figure 1A; Videos 1, 2). The decision was made to proceed with LM CTO PCI.

Right heart catheterization showed normal hemodynamics. We inserted an Impella CP (Abiomed) through the left femoral artery due to the risk of hemodynamic compromise with the retrograde approach through the only graft supplying the left system. We placed two 8 French 45-cm long sheaths through the right femoral artery. Multiple antegrade attempts failed. Multiple retrograde attempts failed due to the blunt distal cap and the difficult angle of penetration. Eventually, an Astato 20 (Asahi Intecc) wire crossed into the left circumflex artery (LCX). We used Shockwave lithotripsy balloon angioplasty from the LM into the LCX in an attempt to fracture the calcium at the distal LM to facilitate reentry into the LAD, but this also failed (Figure 1B, Video 3). We attempted the antegrade antegrade dissection re-entry technique (AADR)² by inflating regular and cutting balloons placed retrogradely into the LAD and attempting to puncture towards it, but this also failed. Lithotripsy performed retrogradely over a Grand Slam wire (Asahi Intecc) also failed to facilitate AADR (Figure 1C, Figure 2A).

We delivered a stent retrogradely to the LAD delivered as a target for the antegrade wire (stent target technique) (Figure 2B). We deployed a 3-mm stent into the proximal LAD over the retrograde wire (Figure 1D, Video 4). We then crossed from the LM into the LAD stent and performed intravascular ultrasound (IVUS)-guided PCI of the LM to the LAD (Figure 1E). We detected a perforation of a small diagonal branch coiled with multiple Interlock coils (Boston Scientific). Final images showed excellent Thrombolysis in Myocardial Infarction (TIMI) 3 flow from LM into the LAD (Figure 1F, Video 5) and patent saphenous vein grafts (SVG) to the OM (Video 6). We removed the Impella CP device after 36 hours and closed the site with the MANTA device (Teleflex). The patient was doing well at the 6-month follow-up.

Retrograde lithotripsy (Figure 2A) can be helpful in calcified LM CTOs supplied by a large collateral (typically an SVG) that allows delivery of the balloon to the distal cap, which can facilitate AADR through microfractures of the calcified CTO body. The stent target technique (Figure 2B) we describe can be useful in LM CTOs supplied by a large SVG through which a stent can be delivered distally to the distal cap to provide a target for the antegrade wire after the failure of other techniques. It is similar to the stent-controlled antegrade and retrograde subintimal tracking (CART) technique that was abandoned due to difficulties when re-entering into the stent, sometimes leading to crossing through the side of the stent struts. However, the stent target technique does not involve stenting the extraplaque space; instead, the stent is implanted into the true lumen distal to the distal cap to provide a target for antegrade wiring. Performing the “stent target” technique requires strong support to facilitate retrograde equipment delivery.

The retrograde stent target technique can facilitate antegrade crossing of LM CTOs in the presence of a reasonable conduit and the failure of other crossing options.

Affiliations and Disclosures

From the ¹Willis Knighton Heart Institute, Shreveport, Louisiana, USA; ²Department of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA; ³Allina Health Minneapolis Heart Institute, Minneapolis, Minnesota, USA.

Acknowledgments: The authors acknowledge Dr. Mariam Tawadros for her help with the illustrations and Dr. Boshra Louka for his help with the case.

Disclosures: Dr Alaswad receives consulting/speaker honoraria from Boston Scientific, Cardiovascular Systems Inc, Abbott Vascular, and Teleflex. Dr. Brilakis receives consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor, Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medtronic, Teleflex, and Terumo; research support from Boston Scientific, GE Healthcare; is the owner of Hippocrates LLC; and is a shareholder of MHI Ventures, Cleerly Health, and Stallion Medical. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Michael Megaly, MD MS, Willis Knighton Heart Institute, 2700 Hearne Ave, Shreveport, LA 71103, USA. Email: michaelmegaly3@gmail.com

References

1.         Xenogiannis I, Karmpaliotis D, Alaswad K, et al. Left main chronic total occlusion percutaneous coronary intervention: A case series. J Invasive Cardiol. 2019;31(7):E220-E225.

2.         Megaly M, Basir MB, Brilakis E, Alaswad K. Side power knuckle and antegrade-antegrade dissection re-entry: techniques to overcome difficulties in chronic occlusion revascularization. JACC Cardiovasc Interv. 2022;15(1):e13-e15. doi: 10.1016/j.jcin.2021.10.008