Retrograde CTO Crossing Through Invisible Collaterals

“We are treating more and more complex coronary CTO lesions, which demand more from the tools available to us. The torque control of the Sion wire and the trackability of the Micro14 are very helpful in such complex PCI cases.”
                                                     — Dr. Bill Nicholson

History

The patient is a 58-year-old gentleman with multivessel coronary disease with a 40% ostial left main lesion, 50% proximal right coronary artery (RCA) lesion and a chronic total occlusion (CTO) of the mid left anterior descending coronary artery (LAD) (Figure 1). He presented with class III angina symptoms despite two anti-anginal medications. A previous attempt at CTO recanalization at an outside institution failed and he was brought to our hospital for a second attempt.   

Case

Access was obtained with a micropuncture needle and bilateral 8 French (Fr) sheaths were obtained. An 8 Fr Judkins right (JR)-4 was used to access the RCA and a 6 Fr Extra Backup (EBU) 3.75 (Medtronic) was used to access the left system, as an 8 Fr 3.75 was not co-axial. Due to the proximal ambiguity and previous failure, a primary retrograde strategy via the posterior descending artery (PDA) to the LAD collaterals was chosen. A Micro14 catheter (Roxwood Medical) was passed to the distal PDA into the septal collaterals over a Whisper wire (Abbott Vascular). A distal tip injection nicely filled and defined the retrograde collaterals (Figure 2). The collateral was wired successfully with a Sion guidewire (Asahi Intecc). Although visible collaterals were present, the wiring occurred via an angiographically invisible accessory connection. The Micro14 catheter tracked the invisible collateral and was placed at the distal cap of the LAD occlusion (Figure 3). A Pilot 200 wire (Abbott Vascular) was used through the Micro14 to pierce the distal cap of the occlusion and advance proximally (Figure 4).

A 6 Fr guide extension catheter was placed in the LAD to allow for localized reverse CART (controlled antegrade and retrograde subintimal tracking). The proximal cap was pierced with a Confianza Pro 12 (Asahi Intecc). A Fighter guidewire (Boston Scientific) was used to facilitate a knuckle into the septal perforator. After dilating the subintimal antegrade channel with a 3.0 x 20 mm balloon, the antegrade wire successfully passed into the true lumen of the distal LAD, completing reverse CART-facilitated antegrade wiring. The retrograde equipment was removed, and a 3.0 x 32 mm Synergy stent (Boston Scientific) was placed and post dilated with a 3.25 mm non-compliant balloon at 20 atmospheres of pressure, with an optimal result.

Intravascular ultrasound (IVUS) imaging was performed out of concern for the left main. IVUS revealed good stent apposition and expansion throughout. There were nice transitions on the proximal and distal stent edges, and the left main was measured at greater than 9.9 mm², resulting in a decision to leave it alone. A complete follow-up angiogram was performed with a multipurpose catheter to confirm. It showed TIMI-3 flow with no evidence of perforation or embolization (Figure 5). 

The patient was discharged the following day without issues and is angina-free at last follow-up. 

Disclosure: Dr. William Nicholson reports he is a proctor and is on the speakers bureau and advisory board for Abbott Vascular, Boston Scientific, and Asahi Intecc; he reports intellectual property with Vascular Solutions. Orlando Marrero reports he is an employee of Boston Scientific. 

Dr. Bill Nicholson can be contacted at wjnichmd2@aol.com. Orlando Marrero, RCIS, MBA, can be contacted at orlm8597@icloud.com.