Successful Percutaneous Coronary Intervention of Chronic Total Occlusion of the RCA Using “Bidirectional Kissing-Balloon” Technique

ABSTRACT: We report on a 74-year-old man with chronic total occlusion (CTO) of the right coronary artery treated with percutaneous coronary intervention using the bidirectional kissing-balloon technique. When an antegrade approach fails, a retrograde approach to recanalize a CTO is reasonable. However, when the exit of the CTO is bifurcated and a protection wire does not advance antegrade into the side branch after wire externalization, loss of blood flow after ballooning or stenting may result. We report on the usefulness of the bidirectional kissing-balloon technique for a retrograde approach to chronically totally occluded coronary arterial bifurcation lesions.

J INVASIVE CARDIOL 2014;26(6):E78-E81

Key words: percutaneous coronary intervention, chronic total occlusion, retrograde approach, kissing-balloon technique

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Percutaneous coronary intervention (PCI) for coronary arterial lesions with chronic total occlusion (CTO) remains one of the most important challenges for interventional cardiologists. Remarkable technical advancements in the antegrade approach, including parallel-wire technique, intravascular ultrasound (IVUS)-guided technique, and subintimal-tracking technique, have contributed to an improved success rate of PCI to treat CTO.^1-3 In addition, when an antegrade approach is not feasible or fails, a retrograde approach to CTO has been widely performed with a high success rate and acceptable complication rate.^4-10 However, when the exit of the CTO is bifurcated, it is sometimes difficult to navigate a second protection wire antegrade into the side branch after wire externalization and may result in loss of the major side branch after ballooning or stenting of the main vessel. When it is difficult to recross the wire antegrade into the side branch, the retrograde balloon angioplasty or bidirectional kissing-balloon techniques are useful to rescue the side branch. We report herein a case of successful PCI of a right coronary artery (RCA) lesion with CTO using the bidirectional kissing-balloon technique.

Case Report. A 74-year-old man presented to our hospital with a chief complaint of chest and back pain on exertion. He was a smoker, but had no other coronary risk factors. Chest x-ray revealed no abnormal findings. Electrocardiography revealed non-specific ST-segment and T-wave changes, but there were no clear findings of prior Q-wave myocardial infarction. Stress myocardial perfusion scintigraphy was performed, and results showed reversible ischemia in the posterior wall. The patient was admitted to our hospital with a diagnosis of stable exertional angina pectoris.

Diagnostic coronary angiography revealed a lesion with CTO in the middle segment of the RCA (Figure 1A). There was no significant stenosis in the left coronary artery. The distal segment of the RCA was supplied mainly by collateral vessels from a major septal branch originating from the left anterior descending artery (Figure 1B). Importantly, the exit of the CTO was a bifurcated site between the posterior atrioventricular (PAV) artery and posterior descending artery (PDA) (Figure 1B). We planned to perform PCI for the RCA CTO to improve the patient’s symptoms.

After obtaining informed consent, PCI of the CTO was performed. An 8 Fr AL1 guiding catheter with a side hole (Mach 1; Boston Scientific) was negotiated into the RCA and a 7 Fr VL3.5 guiding catheter with a side hole (Mach 1) was introduced into the left coronary artery. Because the exit of the CTO was bifurcated and the septal channel was well visualized at the time of diagnostic coronary angiography, we initially attempted a retrograde approach. A Fielder FC guidewire (Asahi Intecc) with a Corsair microcatheter (Asahi Intecc) was introduced into the targeted proximal major septal branch. The guidewire was then removed, and selective tip injection through the Corsair was performed to clarify the connection between the septal branch and the PDA (Figure 2A). The channel was well visualized angiographically, and a Sion guidewire (Asahi Intecc) with a Corsair was successfully introduced into the septal channel. After introducing the guidewire into the distal RCA from PDA to PAV, the Corsair was advanced into the PDA. Tip injection through the Corsair from the PDA was performed, which confirmed that the exit of the CTO was at the point of bifurcation between the PAV and PDA (Figure 2B). The guidewire was then exchanged for a Gaia Second (Asahi Intecc) and advanced retrograde into the CTO from the PDA. Because the retrograde wire was not advanced into the proximal true lumen, reverse controlled antegrade and retrograde subintimal tracking (CART) technique was performed with a 2.5 x 15 mm Sapphire balloon (Orbusneich Medical) (Figure 2C). Finally, a Conquest Pro guidewire (Asahi Intecc) was successfully introduced into the proximal true lumen. The retrograde wire was advanced into the antegrade guiding catheter with the Corsair and exchanged for a 330 cm RG3 guidewire (Asahi Intecc). Wire externalization was then completely achieved.

After wire externalization, we tried to navigate a second protection wire into the PAV with a Crusade double-lumen catheter (Kaneka Medix), but were unsuccessful. Reverse-wire technique using a Fielder FC guidewire was attempted antegrade, but was also unsuccessful. To modify the lesion characteristics, we decided to perform bidirectional kissing-balloon angioplasty. Prior to this, because we had to remove the externalized RG3 guidewire, 2 Xience Prime stents (3.0 x 38 mm and 3.5 x 38 mm) (Abbott Vascular) were deployed from the proximal to the middle segment of the RCA (Figures 2D and 2E) while enough support from the externalized RG3 wire was available. Subsequently, a Sion blue guidewire (Asahi Intecc) was advanced antegrade into the PDA with a Crusade. The RG3 guidewire was removed, and a Route guidewire (Asahi Intecc) was advanced retrograde into the PAV from the PDA through the Corsair. A 2.0 x 15 mm Sapphire balloon (Orbusneich Medical) was advanced into the bifurcation lesion antegrade, and a 1.75 x 15 mm Sapphire balloon (Orbusneich Medical) was advanced retrograde. The bidirectional kissing-balloon technique was then performed (Figure 2F). Following this, we successfully navigated a Balance guidewire (Abbott Vascular) antegrade into the PAV with a Crusade. Subsequently, we performed antegrade kissing-balloon angioplasty with a 2.0 x 15 mm Sapphire balloon in the PDA and a 1.75 x 15 mm Sapphire balloon in the PAV (Figure 2G). A 2.25 x 23 mm Xience Prime stent was deployed from the middle segment of the RCA to the PAV (Figure 2H). Postdilatation was performed with stent balloons, and a final coronary angiogram revealed an excellent result, with preserved flow in both the PAV and PDA (Figure 3). The postprocedure course was uneventful, and no major complications, including severe ischemic events, heart failure, or access-site complications, were observed. The patient was discharged 2 days after the procedure without symptoms.

Discussion. Because of recent improvements in endovascular techniques and devices, the success rate of PCI for CTO has significantly improved.^4-6 However, the success rate of antegrade wire-crossing is relatively low. To date, the main cause of procedural failure of PCI for CTO is unsuccessful wire crossing. A retrograde approach is quite effective when an antegrade approach is not feasible or fails, because the distal fibrous cap is softer and thinner than the proximal one.^6,11 In this respect, the introduction of the retrograde approach to CTO PCI has contributed to the improved success rate of wire crossing.^6-15 Furthermore, even if both an antegrade and a retrograde wire are advanced into the subintimal space of the CTO, the CART or reverse-CART techniques are extremely useful.^12,15

In the present case, we initially performed a retrograde approach because the exit of the CTO was bifurcated and the septal channel was well visualized angiographically. If we initially use an antegrade approach in such a case and the first antegrade wire slides into the subintimal space, it is extremely difficult to rescue the side branch. However, when we use a retrograde approach in this type of bifurcated CTO case, it is sometimes difficult to navigate a second protection wire antegrade into the side branch after wire externalization, even if we use a double-lumen catheter such as the Crusade. Furthermore, a retrograde wire sometimes bypasses the bifurcated lesion and may result in losing the major side branch after ballooning or stenting of the main vessel. Even if the CTO is successfully recanalized, the side-branch occlusion may lead to a worse outcome. The reverse-wire technique¹⁶ is one choice in such a situation, but it was unsuccessful in our case. Although scoring-balloon angioplasty is another option to create a connection between the main vessel and side branch, there is a risk of side-branch occlusion after ballooning when the true lumen of the side branch is not protected with a second guidewire. To modify the lesion characteristics and create a larger connection between the proximal true lumen and the distal side branch, the kissing-balloon technique is a safe and useful method. Furthermore, when it is difficult to navigate a second wire antegrade into the side branch, the bidirectional kissing-balloon technique is an effective way to modify the lesion, as we did in our case. Because the Corsair dilated the septal channel, we delivered a 1.75 x 15 mm Sapphire balloon smoothly retrograde into the PAV. After performing the bidirectional kissing-balloon technique, we succeeded in navigating another wire antegrade into the true lumen of the PAV, because of the modification of the lesion.

To perform the bidirectional kissing-balloon technique, an adequately sized targeted retrograde collateral channel is required. A retrograde approach is contraindicated in patients with no collateral channel and in those with a single collateral channel supplying the only remaining feeding donor artery.¹² The precise angiographic connection should be checked with selective tip injection through a microcatheter before wiring the retrograde channel. After channel dilatation with the Corsair, delivery of the retrograde balloon catheter may be feasible. When performing the bidirectional kissing-balloon technique, one must guard against potential risks of coronary perforation, device-induced thrombosis, retrograde channel injury, and septum hematoma. Those are the complications that have been reported in patients with CTO who underwent PCI with a standard retrograde approach.^12,13,17 Injury to the donor artery or coronary perforation with subsequent cardiac tamponade may result in a life-threatening condition in patients with CTO. However, from the standpoint of retrograde balloon angioplasty, the high success rate and low complication rate of CART technique indicate the safety and feasibility of the bidirectional kissing-balloon technique.^12,13,15 Furthermore, to avoid these serious complications, it is important to select balloons of optimal size and to inflate to an appropriate pressure.

Although PCI for CTO has been performed worldwide, there is a paucity of data regarding this technique. Al Aloul et al18 reported a successful case of PCI for CTO using this technique. They described this technique as the head-to-toe kissing or simultaneous kissing retrograde and antegrade technique (SKRAT); in the present case report, we called this technique the bidirectional kissing-balloon technique. To the best of our knowledge, this is the second case report of CTO PCI using this technique. Our case supports the usefulness, safety, and feasibility of this technique, which was first reported by Al Aloul et al.

Conclusion. In summary, we successfully performed retrograde recanalization of the CTO of a bifurcated RCA using the bidirectional kissing-balloon technique. This case report shows the usefulness, safety, and feasibility of the bidirectional kissing-balloon technique in a retrograde approach to bifurcated lesions of coronary arteries with CTO.

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From the ¹Department of Cardiology, Ashikaga Red Cross Hospital, Tochigi, Japan; and ²Division of Cardiology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted September 8, 2013, provisional acceptance given September 12, 2013, final version accepted September 24, 2013.

Address for correspondence: Yohei Numasawa, MD, Department of Cardiology, Ashikaga Red Cross Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan. Email: numasawa@cpnet.med.keio.ac.jp