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Successful Fenestration Using a Chronic Total Occlusion-Dedicated Guidewire in a Patient with Catheter-Induced Dissection of the Right Coronary Artery
ABSTRACT: Guiding catheter-induced coronary artery dissection is a rare, but hazardous complication of percutaneous coronary intervention (PCI) and is associated with the potential risk of impairment of coronary blood flow. Therefore, occurrence of this complication mandates a prompt revascularization procedure. A 68-year-old female patient with acute myocardial infarction caused by total occlusion of the proximal right coronary artery (RCA) underwent PCI. After revascularization by thrombus aspiration, catheter-induced dissection of the ostium of the right coronary artery (RCA) occurred when the guiding catheter and guidewire were accidentally removed. An attempt to engage the guiding catheter and guidewire into the true lumen failed because of total occlusion of the right coronary ostium. A chronic total occlusion (CTO)-dedicated guidewire was then used to create a fenestration of the intimal flap, and after it penetrated into the distal true lumen, a low-profile balloon catheter was dilated, and coronary flow from the false to the true lumen was established. After balloon dilatation, stents were deployed at both the dissection site and in the distal lesion. The final angiogram revealed restoration of coronary blood flow. We propose that application of a CTO-dedicated guidewire to create a fenestration of the intimal flap in the region of the coronary dissection is a feasible and effective alternative to conventional procedures.
Guiding catheter-induced coronary artery dissection is a rare but serious complication of coronary angiography and percutaneous coronary intervention (PCI).1,2 If it occurs without a guidewire being inserted, the condition could pose a risk, particularly when the dissection compromises coronary blood flow, thereby causing ischemia. To resolve this problem, immediate crossing of the guidewire into the true lumen is essential. However, crossing the guidewire into the true lumen is sometimes difficult due to enlargement of the false lumen. We report a case of catheter-induced ostial dissection of the right coronary artery (RCA) that was successfully treated by creating a fenestration in the intimal flap in the region of the dissection using a chronic total occlusion (CTO)-dedicated guidewire followed by balloon dilatation and deployment of a stent, which restored coronary blood flow. To the best of our knowledge, this is the first case report to demonstrate the efficacy of a CTO-dedicated guidewire for creating a fenestration in the intimal flap in catheter-induced coronary artery dissection.
Case Report
A 68-year-old woman was admitted to the hospital with a history of sudden onset of severe chest pain and cardiogenic shock. Her coronary risk factors were smoking and diabetes mellitus.
Physical examination revealed a blood pressure of 71/33 mmHg and a heart rate of 
46/min. An echocardiogram revealed severe hypokinesis of the inferior wall. Electrocardiography (ECG) showed ST-segment elevation of the inferior leads. Emergency coronary angiography was performed, which showed total occlusion of the RCA (Figure 1). Primary PCI was subsequently performed. After administration of 10,000 units of heparin Na, a 6 Fr Launcher guiding catheter (Medtronic, Inc., Minneapolis, Minnesota) was inserted through the right radial artery.
After engagement of the guiding catheter, a Runthrough NS™ guidewire 
(Terumo, Tokyo, Japan) was advanced into the distal RCA through the occluded lesion, and the thrombus was aspirated. After this procedure, the guiding catheter was found to be too deep-seated. To avoid wedging, it was retrieved slightly; however, during this procedure, the guidewire jumped out 
accidentally. After reintroduction of the guiding catheter, a large dissection of the ostium of the RCA was observed (Figure 2). We tried to re-cross the guidewire for the next 25 minutes, however, this was difficult even after changing the guiding catheter for a Judkins right guiding catheter and the approach site from the right radial to the right femoral artery. We then changed the guidewire to a Conquest Pro™ (Asahi Intecc, Nagoya, Japan), a CTO-dedicated guidewire, and tried to 
create a fenestration from the false to the true lumen. This guidewire was successfully introduced from the proximal false lumen into the distal true lumen after 3 minutes of manipulation. Thereafter, a 1.5 mm balloon catheter was inflated (Figure 3) at the intimal flap, and coronary arterial flow was restored. After reconfirmation of the guidewire position in the distal RCA by intravascular ultrasound, the lumen was dilated using a 2.5 mm balloon catheter, and 3 (3.5 mm × 18 mm, 3.5 × 18 
mm, 3.5 mm × 30 mm) Driver™ stents (Medtronic) were deployed from the ostium of the RCA (Figure 4). The final angiogram showed restoration of coronary blood flow (Figure 5).
Discussion
Coronary artery dissection during PCI is a rather common complication, and has been reported to occur in up to 50% of cases.3 It is usually caused by balloon dilatation and occasionally by excessively vigorous guidewire manipulation, and can be promptly managed with stent deployment. However, catheter-induced coronary dissection occurring either before crossing with the guidewire or after its removal is critical because of the potential risk of acute cessation of coronary circulation and myocardial infarction.4,5 The dissection should be fixed by prompt stent deployment; however, re-crossing of the guidewire is sometimes technically difficult if the true lumen is severely narrowed or occluded and if the entry site of the dissection is located at the origin of the coronary artery since it is usually difficult to properly position the catheter tip at this location. To resolve these problems, several measures including intravascular ultrasound-guided wire manipulation,6 the buddy-wire technique,7 change of the approach site, addition of another guiding catheter from a different approach site, or use of the dummy-wire technique to avoid engagement of the guiding catheter in the coronary ostium are considered effective. However, even with these measures, it is impossible to cross the guidewire into the true lumen in some cases, and such cases require emergency coronary bypass grafting.8,9 Meanwhile, the efficacy of percutaneous balloon fenestration and stenting for preventing ischemic complications of the end organs has been reported in patients with acute aortic dissection.10–12 This procedure can yield more prompt revascularization compared to surgical reperfusion. For coronary dissection, however, suitable devices for fenestration of the intima have not been available. Recent developments in CTO treatment involve the use of guidewires that have the ability to penetrate occluded sites.13,14 In our case, penetration of the intimal flap was easy with the Conquest Pro, and instant revascularization was achieved after an initial time-consuming attempt to cross to the occluded true lumen.
This procedure appears to be promising and we consider it very useful. To the best of our knowledge, this is the first case report describing the efficacy of a CTO-penetrable guidewire for penetrating an intimal flap in catheter-induced coronary artery dissection. Nonetheless, several potential adverse aspects of this procedure should be noted including distal guidewire perforation, enlargement of the false lumen during guidewire manipulation, migration of the guidewire tip to the distal subintimal space and stent thrombosis or restenosis due to multiple stents. In addition, confirming guidewire entry into the true lumen is problematic, especially in cases where there is total occlusion. Broad expertise and experience with these devices with regard to CTO cases are necessary. Stenting of the false lumen is considered a potential risk for stent restenosis and occlusion.15 As already reported from the long-term follow up of the STAR technique, stenting of the subintimal space in a CTO setting16 results in a high restenosis rate.17
Conclusion
As a backup for coronary dissection, crossing of the guidewire into the true lumen from the entry point of the dissection is ideal. However, when this fails, we believe that fenestration of the intimal flap from the false lumen using a CTO-dedicated guidewire is feasible and effective.
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From the Department of Cardiology, Sakurakai Takahashi Hospital, Ooikecho, Sumaku, Kobe, Hyogo, Japan. The authors report no financial relationships or conflicts of interest regarding the content herein. Manuscript submitted August 9, 2010, provisional acceptance given August 30, 2010, final version accepted September 7, 2010. Address for correspondence: Akihiko Takahashi, MD, PhD, Department of Cardiovascular Medicine, Sakurakai Takahashi Hospital, Ooikecho, Sumaku, Kobe, Hyogo 654-0026, Japan. E-mail: a-takahashi@wine.ocn.ne.jp
