Snaring the Retrograde Wire in the Aortic Root for Chronic Total Occlusion after Bentall Operation (Full title below)

Snaring the Retrograde Wire in the Aortic Root for Chronic Total Occlusion after Bentall Operation in a Patient with Behcet’s Disease

From the Division of Cardiology and *Radiology, National Cardiovascular Center, Suita, Osaka, Japan. The authors report no conflicts of interest regarding the content herein. Manuscript submitted December 31, 2008, provisional acceptance given April 6, 2009, and final version accepted April 7, 2009. Address for correspondence: Yoritaka Otsuka, MD, FACC, Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center, Fujishirodai 5-7-1, Suita Osaka, 565-8565, Japan. E-mail: yotsuka@hsp.ncvc.go.jp

_______________________________________________ ABSTRACT: Snaring the retrograde wire in the aortic root was successfully performed for treatment of a chronic total occlusion (CTO) lesion of a saphenous vein graft interposed between a prosthetic graft and the right coronary artery (RCA) ostium in a patient with Behcet’s disease after two Bentall operations. Although the coronary guidewire and balloon were able to cross the CTO lesion retrogradely, the coronary guidewire was unable to cross antegradely after ballooning because of intractable engagement of the guiding catheter. A 300 cm guidewire was inserted retrogradely and the guidewire was pulled out of the sheath placed in the right radial artery using a snare. Subsequently, the micro-catheter was inserted antegradely into the RCA using the guidewire. The 300 cm guidewire was removed and a standard guidewire was inserted antegradely into the RCA. Finally, a drug-eluting stent was successfully implanted in this difficult-to-treat CTO lesion. Key words: Percutaneous coronary intervention; chronic total occlusion, retrograde approach

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J INVASIVE CARDIOL 2009;21:e137–E140 Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of coronary arteries is one of the most technically challenging areas for the interventional cardiologist, with lower procedural success rates compared with those for the non-occluded coronary arteries or acutely occluded arteries. In addition, clinical and angiographic restenosis or reocclusion occurs with greater frequency after PCI of CTOs compared with non-occluded lesions.1 It has been reported that successful revascularization of a CTO leads to a significantly improved survival rate and a reduction in major adverse cardiac events in patients in the long term.2–4 Recently, drug-eluting stents (DES) have been demonstrated to markedly reduce in-stent restenosis for on-label and off-label lesions5,6 such as CTO lesions.7,8 Long-term patency and freedom from restenosis after successful recanalization of CTOs with DES greatly reduce the rate of mortality and cardiac events. More recently, several procedural techniques such as the retrograde approach and various devices for CTO lesions have been developed and success rates of CTO recanalization have increased throughout the world.9–12 In the present case report, we demonstrate that snaring the retrograde wire in the aortic root using a retrograde approach was successful in treating a CTO lesion in a patient with Behcet’s disease after repeated Bentall operations. Case Presentation. The patient was a 38-year-old male with Behcet’s disease. His medical history showed that a Bentall operation had been performed because of severe aortic regurgitation and a partially ruptured aneurysm of the sinus of Valsalva 3 years earlier. At that time, the ostia of left and right coronary arteries were anastomosed using the button technique. The patient had progressive angina due to left main trunk compression caused by multiple large pseudoaneurysms (Figure 1a) and urgently underwent another Bentall operation and coronary bypass surgery 1 year after the first Bentall operation. Bypass surgery was performed using a saphenous vein graft (SVG) extending from the prosthetic graft at the ascending aorta to the left anterior descending artery (LAD) (Figure 1b) and the SVG was interposed between the prosthetic graft and the right coronary artery (RCA) ostium (Figure 1c). After the second Bentall operation, the patient experienced recurrence of angina pectoris because of stenosis at the bypass anastomosis site. Because he refused another bypass surgery, we implanted 2 Cypher™ stents (Cordis Corp., Miami Lakes, Florida), 1 in the LMT and 1 in the mid-LAD. One year after PCI, he was readmitted to the hospital because of ventricular tachycardia and cardiogenic shock. Emergency coronary angiography showed total occlusion of the SVG of the RCA and in-stent restenosis of both the left main trunk (LMT) and the mid-LAD. We immediately performed implantation of Cypher stents for in-stent restenosis of the Cypher stent at the LMT and the mid-LAD under intra-aortic balloon pump support. Although there was no recurrence of restenosis at 1 year after Cypher-in-Cypher treatment, CTO of the RCA still existed and the patient had severe left ventricular dysfunction (left ventricular ejection fraction 21%). Multi-slice computed tomographic imaging of the heart showed complete occlusion of the RCA and attached SVG. There was no clear demarcation site or stump on the ascending aortic prosthetic graft (Figures 2a and b). PCI was performed using a retrograde approach with a 7 Fr BL 3.5 85 cm Heartrail™ guiding catheter (Terumo, Japan) via the left femoral artery. In this case, collateral supply was mainly from the left circumflex artery and the epicardial collateral vessel had a corkscrew appearance (Figure 3a). Although the collateral vessel from the septal branch appeared to be narrow, we chose the septal branch for the retrograde approach because of severe left ventricular dysfunction. A Fielder-FC™ guidewire (Asahi Intecc, Japan) and a Finecross™ microcatheter (Terumo) were used to select the first septal branch and the Finecross™ microcatheter was advanced into the septal branch. Then, a superselective tip injection of contrast was performed and a microchannel from the septal branch to the distal RCA was confirmed (Figure 3b). A Fielder-FC guidewire was advanced into the distal RCA (Figure 3c) and the Finecross microcatheter was advanced toward the distal part of the CTO lesion. A Pilot 50™ guidewire (Abbott Vascular, Abbott Park, Illinois), a Miracle™ 6, a Miracle™ 12, and a Conquest Pro™ guidewire (Asahi Intecc) were used to cross this CTO lesion, but they were unable to cross the proximal CTO lesion because of a twist in the lesion. Subsequently, a Finecross microcatheter was further advanced into the CTO lesion and the Pilot 50 guidewire (Abbott Vascular) was finally able to cross this CTO lesion. A 1.25 mm x 15 mm Ryujin™ balloon (Terumo) was able to cross and was successfully opened in this CTO lesion (Figure 3d). A 2.0 mm x 15 mm Ryujin™ balloon (Terumo) was then used to open this CTO lesion further. However, the coronary guidewire was unable to cross the RCA through a 6 Fr AL 0.75 100 cm Heartrail™ guiding catheter (Terumo) antegradely via the right radial artery because of intractable engagement of the guiding catheter, and it proved impossible to control the coronary guidewire. Subsequently, a Finecross™ microcatheter was retrogradely advanced and crossed the CTO lesion (Figure 3e), and the coronary guidewire was exchanged for a 300 cm BMW™ guidewire (Boston Scientific, Natick, Massachusetts). The 300 cm retrograde guidewire was snared in the aortic root and was pulled out of the sheath placed in the right radial artery using a GooseNeck™ snare (ev3, Inc., Plymouth, Minnesota) (Figure 3f). A Finecross microcatheter with a guiding catheter was inserted antegradely into the RCA using this guidewire and the 300 cm guidewire was removed after retrograde advancement of another microcatheter (Figure 3g). Another guidewire was inserted antegradely into the microcatheter and a 3.0 mm x 30 mm Apex™ balloon (Boston Scientific) was successfully opened in the CTO lesion. Stent implantation was successfully performed using a 3.5 mm x 28 mm Cypher stent for the CTO lesion and a 3.5 mm x 15 mm Hiryu™ (Terumo) balloon was used for high-pressure postdilatation. A final coronary angiogram showed a satisfactory result without any complications (Figure 3h). Discussion. We demonstrated with this case that snaring the retrograde wire in the aortic root was successful in treating a CTO lesion in a patient with Behcet’s disease after repeated Bentall operations. PCI for CTO recanalization is one of the most technically challenging areas for the interventional cardiologist, with a lower procedural success rate compared with that for nonoccluded arteries.1 It has been reported that successful revascularization of a CTO leads to a significantly reduced frequency of mortality and cardiac events in the long term.2–4 Recently, several procedural techniques and various devices for CTO lesions have been developed.13,14 The retrograde approach for treatment of a CTO lesion has been recently recognized as a novel useful approach.9–12 In this patient, an SVG was interposed between the prosthetic graft and the RCA ostium and the SVG was occluded. Moreover, the suturing site of the SVG to the prosthetic graft had no identification mark and no stump that could be seen with aortography or multi-slice computed tomography. Therefore, we were unable to engage the guiding catheter and it was impossible to perform PCI using an antegrade approach. Saito recently reviewed the different strategies of the retrograde approach in PCI for CTO after crossing a guidewire.9 Our strategy in this patient was similar to “catching the retrograde guidewire” strategy, but this technique has rarely been used. This strategy was used in only 5% of the patients after successful guidewire passage in the study noted above.9 Because we were unable engage the antegrade guiding catheter, we could not perform the so-called “catching the retrograde guidewire technique”. Although snaring the retrograde wire is an established technique in a variety of interventional situations, snaring the retrograde wire in the aortic root has not been reported. We used the snare and the tip of the 300 cm guidewire finally came out the proximal end of the radial sheath and could be caught. Of note, due to significant resistance, we inserted the two microcatheters, one antegradely, and the other retrogradely, for removing a 0.014 inch standard 300 cm guidewire.

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5. Beohar N, Davidson CJ, Kip KE, et al. Outcomes and complications associated with off-label and untested use of drug-eluting stents. JAMA 2007;297:1992–2000.

6. Marroquin OC, Selzer F, Mulukutla SR, et al. A comparison of bare-metal and drug-eluting stents for off-label indications. N Engl J Med 2008;358:342–352.

7. Nakamura S, Muthusamy TS, Bae JH, et al. Impact of sirolimus-eluting stent on the outcome of patients with chronic total occlusions. Am J Cardiol 2005;95:161–166.

8. García-García HM, Daemen J, Kukreja N, et al. Three-year clinical outcomes after coronary stenting of chronic total occlusion using sirolimus-eluting stents: Insights from the rapamycin-eluting stent evaluated at Rotterdam cardiology hospital-(RESEARCH) registry. Catheter Cardiovasc Interv 2007;70:635–639.

9. Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv 2008;71:8–19.

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11. Sheiban I, Moretti C, Omedé P, et al. The retrograde coronary approach for chronic total occlusions: Mid-term results and technical tips and tricks. J Interv Cardiol 2007;20:466–473.

12. 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.

13. Stone GW, Colombo A, Teirstein PS, et al. Percutaneous recanalization of chronically occluded coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc Interv 2005;66:217–236.

14. Stone GW, Reifart NJ, Moussa I, et al. Percutaneous recanalization of chronically occluded coronary arteries: A consensus document: Part II. Circulation 2005;112:2530–­2537.