Contact Wire Technique: A Possible Strategy for Parallel Wire Techniques

Successful recanalization of chronic total occlusion (CTO) improves left ventricular function1 and survival.² There are, however, several difficulties with percutaneous coronary intervention (PCI) for CTO (CTOPCI). Failure to cross the occlusive lesion with a guidewire is the main cause of unsuccessful CTO-PCI.^3,4 The parallel wire technique is common and useful for CTO-PCI.⁵ However, the parallel wire technique has some limitations, especially for tortuous CTO morphology. In order to manage tortuosity or acute bending, we employ the “contact wire technique” and make the second guidewire contact the first guidewire. Contact resistance is created as a result, and the resistance plays an important role in making a pivot for the second guidewire. This enables the second guidewire to turn at this contact point, allowing it to further advance inside the CTO body. We describe a case in which this technique was used.

Case Report. A 71-year-old male was referred to our institution for PCI of the left anterior descending artery (LAD). He underwent 2-vessel coronary artery bypass surgery (saphenous vein bypass graft [SVG]–LAD; SVG–first diagonal branch) 19 years prior to admission. In the present admission, the patient presented with chest pain, and diagnostic coronary angiography (CAG) showed a total occlusion of the 2 SVGs, a CTO of the ostial LAD, which was perfused via collaterals from the right coronary artery (RCA), and a new tight lesion of the mid RCA. PCI of the mid RCA, with stent implantation, was successfully performed. Elective percutaneous recanalization of the LADCTO was scheduled 2 weeks after. PCI of the LAD-CTO was started with an 8 Fr AL-1 guide catheter engaged in the LAD and a 6 Fr JR4 to the RCA via right femoral approaches. Bilateralangiography showed a short CTO starting from the LAD ostium without a visible stump. The report from 19 years prior revealed that the LAD was acutely bent at its proximal segment (Figure 1A). After determining the entry point of this CTO using intravascular ultrasound (IVUS), an antegrade approach was initiated using a moderately stiff wire with which it was possible to enter the proximal CTO segment. However, it was not possible to follow the tortuous vessel course because the guidewire was advancing straight into a small branch in the opposite side of true lumen (Figure 1B). A stiffer guidewire also went in a straight direction to the same small branch. Next, the conventional parallel wire technique was tried. The stiffer guidewire (as a first guidewire) was left in the small branch and moderately stiff guidewire (as a second guidewire) was manipulated to cross the CTO lesion. The second guidewire was inserted parallel to the first one inside the proximal CTO portion. The second guidewire, however, followed the same route as the first guidewire. We then manipulated the second guidewire to create contact between it and the first guidewire so it would turn in the desired direction (Figure 1C) and proceed inside the CTO body up to the distal true lumen. Predilatation followed by implantation of 2 overlapping Cypher stents (Cordis Tokyo, Japan) was then performed. Final kissing balloon was done at the LAD and left circumflex artery with a good final result (Figure 1D).

Discussion. The parallel wire technique has been established as one of the most helpful techniques for CTO recanalization. To facilitate the penetration of the second guidewire into the true lumen, the first guidewire is left in the false lumen along the CTO body. The first guidewire could: (a) serve as a guidepost of the false lumen; (b) prevent the second guidewire from entering the false lumen in which the first guidewire has been left; and (c) slightly stretch the vessel. However, the parallel wire technique has some limitations, as was illustrated in the present case report, in which the second guidewire was unable to be directed to the true lumen. We therefore made contact between the second guidewire and the first guidewire, thus creating contact resistance. The resulting contact resistance played an important role in making a pivot for the second guidewire and enabled the second guidewire to face and advance to the true lumen (Figure 2). This technique has the same advantages as the conventional parallel wire technique. There is, however, an additional advantage with this method in that the second guidewire can be redirected in the desired direction. This advantage makes it easier to determine the correct way to advance the guidewire into the true lumen, especially in cases of tortuous CTOs.

References

1. Chung CM, Nakamura S, Tanabe K, et al. Effect of recanalization of chronic total occlusion on global regional left ventricular function in patients with or without previous myocardial infarction. Catheter Cardiovasc Interv 2003;60:368–374.

2. Suero JA, Marso SP, Jones PG, et al. Procedural Outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: A 20-year experience. J Am Coll Cardiol 2001;38:409–414.

3. Bell MR, Berger PB, Bresnahan JF, et al. Initial and long-term outcome of 354 patients after balloon coronary angioplasty of total coronary artery occlusions. Circulation 1992;85:1003–1011.

4. Puma JA, Sketch MH Jr, Tcheng JE, et al. Percutaneous revascularization of chronic total occlusions: An overview. J Am Coll Cardiol 1995;26:1–11.

5. M Ochiai, K Ashida, H Araki, et al. The latest wire technique for chronic total occlusion. Ital Heart J 2005;6:489–493.