Retrograde Approach to a Totally Occluded Right Coronary Artery via a Septal Perforator Artery (full title below)

Retrograde Approach to a Totally Occluded Right Coronary Artery via a Septal Perforator Artery: The Tale of a Long and Winding Wire

ABSTRACT: Retrograde recannalization of chronic total occlusions has developed as a viable alternative to restore coronary patency. Techniques continue to evolve and complications described. We present a new complication related to equipment developed to improve outcomes via a retrograde approach. J INVASIVE CARDIOL 2010;22:E65–E66 Key words: chronic total occlusion; percutaneous coronary intervention
Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is a technique that has recently garnered increasing interest, both with respect to procedural technique, indications and long-term outcomes.^1–3 The retrograde approach is gaining favor, as the distal cap of the CTO is frequently more amenable to guidewire passage than is the proximal cap. ⁴ When the chosen pathway for a given CTO involves a retrograde approach via a septal perforator artery, its use provides some degree of safety, in that perforations typically are self-contained within the muscular interventricular septum. However, perforations of epicardial arteries can result in catastrophe pericardial effusion and tamponade. We describe a complication of retrograde approach via septal perforator to right coronary artery (RCA) CTO that has not been reported previously. Case Report. A 49 year old male with known coronary artery disease, hypertension, dyslipidemia, diabetes and obesity had a stent placed 6 years ago. He had bare-metal stents implanted in the circumflex artery (CFX) 18 months earlier and had a known RCA CTO with left-to-right collaterals. After he developed recurrent angina 12 months later, he had drug-eluting stents implanted for in-stent restenosis of the CFX. After another 6 months, he re-presented with stable angina. A pharmacologic nuclear stress test showed a small non-transmural infarct with peri-infarct ischemia in the inferior wall. The patient’s repeat angiography showed the CTO to be 40 mm long with patent CFX stents. An antegrade attempt to reach the CTO was unsuccessful. His symptoms persisted. A retrograde attempt was made by intubating the left main with an XB 3.5 guide catheter. A 190 cm Pilot-50 guidewire (Abbott Vascular, Santa Clara, California) with an Apex Push 1.5 x 15 mm over-the-wire balloon (Boston Scientific Corp., Natick, Massachusetts) was passed via the left anterior descending artery to a large septal perforator artery that was supplying collateral flow to the posterior descending artery (PDA). Once the septal artery had been engaged with the Pilot guidewire, and the OTW balloon was secured in the septal artery, the Pilot-50 guidewire was exchanged for a 300 cm Fielder guidewire (Abbott Vascular, Santa Clara, California). The guidewire did not cross over to right PDA. Next, the Fielder guidewire was exchanged for the tapered-tip Fielder XT (Abbott Vascular, Santa Clara, California). The guidewire appeared to pass through the collateral channels into the PDA. The OTW balloon was advanced without resistance and the guidewire was removed when the balloon reached the segment thought to be a proximal segment of the PDA. Contrast injection through the lumen of the OTW balloon was then performed to confirm intraluminal positioning. However, contrast, although flowing forward, did not appear to go towards the PDA (Figure 1A). A contrast injection with followthrough in the levo phase showed the balloon in the coronary sinus (Figure 1B) and the forward flow was further confirmed to the coronary sinus and then to the right atrium as the balloon was withdrawn back further (Figures 1C and 1D). The procedure was aborted. There was no hemodynamic compromise on observation in the hospital and patient was managed on medical therapy. Discussion. The retrograde approach for CTO is a relatively new treatment strategy with its attendant complications having not yet been fully appreciated and described. The use of the retrograde approach in combination with the antegrade approach has increased the success rate in recanalizing CTOs to 80–90% or more.⁵ Various guidewire maneuvers and equipment are frequently required to successfully perform this complex procedure. Various complications that have been described in the literature including radiation injury from lengthy procedures, periprocedural myocardial infarction, dissection of the donor artery in the search for an acceptable septal collateral, and septal artery perforation resulting in septal hematoma and/or pericardial tamponade in rare case scenario.^6,7 Newer guidewires with a hydrophilic tip (Fielder, Fielder-FC or Fielder X-treme, Asahi Intec, Japan) and specially tapered tips to 0.009 inch (Fielder XT) may provide an even greater ability to traverse tiny vessels. There is the increased risk that the ease of movement may cause the wire to arrive at unwanted destinations. In our case, the Fielder XT crossed from the septal perforator to the coronary sinus. To our knowledge, this path of the guidewire from the septal perforator to the coronary sinus has not been described before. Because of the tapered tip of the guidewire, it enabled the operator to cross over from the arterial side through a capillary channel to the venules and ultimately to the coronary sinus. This case highlights the ease with which newer guidewires may pass into the subintimal space or into adjacent cardiac structures and represent a potential source for complications if inadvertent balloon dilatation is performed.

References

1. Surmely JF, Katoh O, Tsuchikane E, et al. Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv 2007;69:826–832.

2. Surmely JF, Tsuchikane E, Katoh O, et al. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: The CART technique. J Invasive Cardiol 2006;18:334–338.

3. Lee NH, Seo HS, Choi JH, et al. Recanalization strategy of retrograde angioplasty in patients with coronary chronic total occlusion — Analysis of 24 cases, focusing on technical aspects and complications. Int J Cardiol 2009 May 5.

4. Ozawa N. A new understanding of chronic total occlusion from a novel PCI technique that involves a retrograde approach to the right coronary artery via a septal branch and passing of the guidewire to a guiding catheter on the other side of the lesion. Catheter Cardiovasc Interv 2006;68:907–913.

5. Rathore S, Katoh O, Matsuo H, et al. Retrograde percutaneous recanalization of chronic total occlusion of the coronary arteries: Procedural outcomes and predictors of success in contemporary practice. Circ Cardiovasc Intervent 2009;2:124–132.

6. Matsumi J, Adachi K, Saito S. A unique complication of the retrograde approach in angioplasty for chronic total occlusion of the coronary artery. Catheter Cardiovasc Interv 2008;72:371–378.

7. Lin TH, Wu DK, Su HM, et al. Septum hematoma: A complication of retrograde wiring in chronic total occlusion. Int J Cardiol 2006:113:e64–e66.

_________________________________________________ From the Division of Cardiovascular Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, and Central Arkansas Veterans Healthcare System, Little Rock, Arkansas. The authors report no conflicts of interest regarding the content herein. Manuscript submitted August 27, 2009, provisional acceptance given September 9, 2009, final version accepted September 14, 2009. Address for correspondence: Rajesh Sachdeva, MD, Central Arkansas Veterans Healthcare System, 4300 W. 7th Street, Little Rock, AR 72205. E-mail: RSachdeva@uams.edu