Never Say Never: Successful Use of the Step-By-Step Technique in the Coronary Arteries

History and Methods

A 61-year-old former smoker presented with angina pectoris and a known right coronary artery occlusion. The patient had a family history of heart disease and had undergone percutaneous transluminal coronary angioplasty (PTCA) and stent placement to treat a 90% stenosis 4 years prior in the mid portion of the right coronary artery (RCA). A year later, the RCA was found to be 100% occluded in the mid portion of the vessel and there was no left coronary disease. 

Inferior ischemia was identified by non-invasive testing, but an outside cardiologist felt that medical therapy was sufficient, because the patient had some distal collateral vessels and moderate angina. 

Due to continued increasing angina, the patient was evaluated by our group, and we attempted to recanalize the RCA with standard techniques via the radial approach (Figure 1). After these techniques failed, the patient returned for another session. We used the step-by-step method in an attempt to recanalize the RCA using the CrossLock device (Radius Medical) and Indigo CAT RX aspiration catheter (Penumbra) to remove any thrombus. The step-by-step technique for occluded vessels is typically performed only in the peripheral vessels. We have used the step-by-step technique in the coronary arteries for in-stent restenosis, though only with a centering device such as the CrossLock device. 

Procedure

We entered from the right groin, and, using an 8 French right coronary artery Judkins guide catheter (Medtronic), passed the CrossLock device, as well as an 0.9 mm excimer coronary laser angioplasty (ECLA) catheter (Philips), and a Miracle 3 wire (Asahi Intecc). After entering the proximal third of the chronic total occlusion (CTO), we switched to a 7 French Amplatz guide catheter (Boston Scientific) and a Fielder XT guidewire (Asahi Intecc) (Figure 2). With the Fielder, we were able to travel approximately halfway across the vessel and address the lesion with the laser. We then passed the Whisper wire (Boston Scientific) into the posterior branch of the RCA, completely recanalizing the CTO (Figure 3). After recanalization, we performed balloon angioplasty with a 1.5 mm Somerset balloon (Terumo), followed by a 4 mm balloon in the proximal portion of the in-stent restenosis (Figures 4-5). 

There was an excessive amount of plaque and thrombus in the vessel, so the McNamara catheter (Medtronic) was inserted and 4 mg of intra-arterial tissue plasminogen activator (tPA) was infused in the occluded vessel (Figures 6-8). After re-inserting the .014-inch wire, five slow passes were made with the Indigo CAT RX aspiration catheter in order to remove thrombus from the totally occluded vessel. Afterwards, an angiogram confirmed TIMI-3 flow with no more thrombus observed, but the vessel was diffusely diseased (Figure 9). We performed balloon angioplasty and subsequent stenting, placing a 2.75 × 38 mm Resolute Onyx drug-eluting stent (Medtronic) distally and two 4.5 × 38 mm drug-eluting stents proximally. At the origin of the vessel, a 5 × 20 mm drug-eluting stent was placed using an Ostial Flash balloon (Ostial Corporation) to optimize the origin of this stent (Figure 10). Following this final procedure, angiography demonstrated a widely patent RCA with TIMI-3 flow (Figures 11-12). 

Discussion

In the past, we have been confronted with similarly aggressive in-stent restenosis and a full metal jacket. The use of a CrossLock catheter allows our off-label approach to be performed as a result of the centering ability of the CrossLock device. The laser ablates without perforation because it is centered in the aggressive in-stent restenosis. Many operators who are experienced in CTO intervention have been plagued with no reflow or spasm in vessels of this type, when residual thrombus is in fact present in the vessel. The technique of using a centering catheter, ablative catheter, and thrombolytic catheter allowed for efficient treatment of a difficult chronic total occlusion. This is a technique that could be utilized in other circumstances of aggressive in-stent restenosis, or even in calcified CTOs.

Conclusion

The step-by-step method is not an FDA-approved treatment in coronary or peripheral disease. However, using a centering catheter, laser, and a thrombolytic device such as the Indigo CAT RX aspiration catheter device, we were able to effectively treat a CTO that had a full metal jacket in-stent reocclusion.   

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Disclosure: The corresponding author has an affiliation with Radius Medical and the CrossLock device. Dakota McNierney has no potential conflicts.

Manuscript submitted May 30, 2019; accepted June 11, 2019.

Address for correspondence: Richard R. Heuser, MD, FACC, FESC, FACP, MSCAI,  Chief of Cardiology, St. Luke’s Medical Center, Phoenix, Arizona; Professor of Medicine, University of Arizona School of Medicine, Phoenix, Arizona, Phoenix Heart Center, 555 North 18th Street, Suite 100, Phoenix, Arizona 85006.
Email:  rheuser@phoenixheartcenter.com