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Successful Retrograde Recanalization of a Left Anterior Descending Artery Chronic Total Occlusion (Full title below)
Successful Retrograde Recanalization of a Left Anterior Descending Artery Chronic Total Occlusion through a Previously Placed Left Anterior Descending-to-Diagonal Artery Stent
pg. E16 - E18 ABSTRACT: Since the introduction of the retrograde technique, the success rate of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has increased significantly in patients with suitable anatomy. To our knowledge, retrograde recanalization of a CTO from the abluminal side of a previously placed stent has not been reported. We describe a case of retrograde PCI of a mid left anterior descending (LAD) artery CTO through a previously placed proximal LAD stent which extended into the diagonal artery. The occluded mid LAD was recanalized using the retrograde approach in which retrograde wire crossing into the proximal LAD was successful only after high pressure balloon expansion of the previously placed proximal LAD-to-diagonal stent. Intravascular ultrasound imaging was also used to confirm an intraluminal location of the retrograde guidewire. J INVASIVE CARDIOL 2010;22:E16–E18 Key words: Percutaneous coronary intervention, stenting, angioplasty, intravascular ultrasound Since the introduction of the retrograde technique, the success rate of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions has increased to the 70–90% range in patients with suitable anatomy.1–6 Multiple strategies of the retrograde approach have been described, including the retrograde application of the ‘‘buddy’’ wire technique,7 the controlled antegrade and retrograde subintimal tracking (CART) technique,1,8 the parallel wire technique,9 and the double anchoring balloon technique.10 To our knowledge, retrograde recanalization of a CTO from the abluminal side of a previously placed stent has not been reported. We describe a case of retrograde PCI of a mid left anterior descending (LAD) artery CTO through a previously placed proximal LAD stent which extended into the diagonal artery. The vessel was recanalized using the retrograde approach in which retrograde wire crossing through the stent strut into the LAD lumen (from the abluminal side of the stent) was achieved only after balloon expansion of the previously placed LAD stent. In addition, intravascular ultrasound (IVUS) imaging was used to verify an intraluminal position of the retrograde wire. Case report. A 67-year-old woman presented with persistent exertional angina despite medical therapy. Three years ago, she was admitted emergently because of an acute anterior wall myocardial infarction. Coronary angiography showed a 75% proximal stenosis of a dominant right coronary artery (RCA) and sequential 100% occlusion of the proximal and mid LAD, with a large diagonal artery arising between the occluded segments. The distal LAD was filled via right-to-left collaterals from septal perforators of the posterior descending artery (PDA). The mid LAD occlusion could not be crossed after several attempts, including use of a Miracle Bros 3g (Asahi Intec, Abbott Vascular, Redwood City, California) wire. As a result, she received overlapping 2.5 x 28 mm and 2.5 x 23 mm Cypher (Cordis, Johnson & Johnson, Miami Lakes, Florida) stents which extended from the proximal LAD into the diagonal artery. The RCA lesion was treated with a 2.5 x 23 mm Cypher stent. Despite successful LAD and RCA intervention, she continued to have limiting symptoms and documented anterior wall ischemia on nuclear imaging. Given the advances in equipment and refinement in the retrograde technique, we decided to attempt recanalization of the mid LAD CTO using the retrograde approach via the septal collaterals from the PDA. After bilateral femoral artery access was obtained, coronary angiography revealed patent stents in the RCA and the LAD-diagonal arteries. The mid-LAD CTO with right-to-left collateral filling appeared similar (Figure 1). Heparin 80 units/kg bolus was administered intra-arterially and IVUS imaging of the LAD was performed to determine LAD vessel caliber and stent diameter. A 7 Fr XB 3.5 guide catheter with sideholes was used to engage the left main coronary artery. A 7 Fr IMA guide catheter with sideholes was used to engage the right coronary artery. A Prowater (Abbott Vascular) guidewire was loaded onto a Corsair (Asahi Intec, Abbott Vascular) channel dilator catheter and this system was advanced into the PDA. The Prowater wire was then replaced by a Fielder FC (Asahi Intec, Abbott Vascular) guidewire. The Fielder FC wire was successfully directed into the septal perforator toward the LAD, followed by advancement of the Corsair channel dilator to provide additional guidewire support. The Fielder FC guidewire was then exchanged for a Fielder XT (Asahi Intec, Abbott Vascular) guidewire to probe the occlusion site. However, the Fielder XT wire could not be advanced across the CTO (into the LAD-to-diagonal stent from the abluminal side). Additional attempts using the Miracle Bros 3.0 and Confianza Pro (Asahi Intec, Abbott Vascular) guidewires were also unsuccessful. To increase LAD-to-diagonal stent strut separation, high pressure balloon angioplasty of the LAD stent was performed using a 3.0 x 15 mm NC Voyager (Abbott Vascular) balloon catheter inflated to 18 atm of pressure. Subsequently, a Confianza Pro guidewire was successfully advanced through the stent strut (from the abluminal side) into the mid LAD in a retrograde fashion. (Figure 2) Intraluminal location of the guidewire was confirmed by IVUS imaging of the proximal LAD stent. The Corsair channel dilator was then advanced across the occlusion site and was positioned in the proximal LAD. The Confianza Pro guidewire was replaced by a 180 cm Fielder FC with a large bend, which was directed into the XB guide catheter. Next, the Corsair catheter was advanced into the distal end of the guide catheter. The 180 cm Fielder FC wire was then replaced by a 300-cm Fielder FC wire which was externalized through the Copilot of the XB guide catheter. A 1.8 Fr FineCross MG (Terumo Interventional Systems, Somerset, New Jersey) catheter was then advanced in an antegrade fashion over the Fielder FC wire and was positioned into the distal LAD. The Fielder FC wire was then replaced by an exchange length Choice ES (Abbott Vascular, Redwood City, California) wire, after which the Corsair catheter was removed. Balloon angioplasty of the LAD occlusion was performed using a 2.0 x 20 mm Voyager (Abbott Vascular) balloon catheter. Overlapping 2.5 x 28 mm Xience (Abbott Vascular) DES and 3.0 x 18 mm Xience DES were placed from the distal to proximal LAD. Sequential post-stent high-pressure balloon dilatation was performed using a 3.0 NC Voyager balloon in the LAD at 18 atm and a 2.5 x 20 mm NC Voyager balloon in the diagonal artery at 18 atm, followed by a kissing balloon inflation at 14 atm (Figure 3). Final imaging of the LAD demonstrated 0% residual stenosis and TIMI III flow in the LAD (Figure 4). The patient was discharged the next day and has remained free of angina 3 months later. Discussion. Successful recanalization of CTO remains one of the greatest challenges in interventional cardiology. Predictors of procedural success in CTO PCI include length of occlusion, presence of side branch at the occlusion site, occlusion morphology, and presence of bridging collaterals.11 Despite advances in equipment and greater operator experience, the success of antegrade CTO PCI has remained in the 60–70% range. Histologically, CTO usually consists of a fibrous cap at the proximal and distal margins, cholesterol and fibrocalcific material within the CTO, and microvascular channels.12 Compared to the distal cap, the proximal cap may be more fibrotic and difficult to penetrate. Consequently, the retrograde approach may be a superior strategy in those patients with suitable anatomy. Successful retrograde recanalization of CTO through native arteries can be accomplished via epicardial collateral arteries or septal collateral arteries. Because perforation of epicardial collaterals carries a higher risk of catastrophic complications, a retrograde strategy using septal collaterals has been the preferred approach.1,13,14 Our case of retrograde PCI of an LAD CTO via septal collaterals is unique because it was performed through the abluminal side of a previously placed stent. Despite using the Confianza Pro wire, initial CTO entry was not technically feasible, which we believe was due to neointimal proliferation over the stent struts. By using high-pressure balloon angioplasty of the proximal LAD stent, we were able to increase strut separation and inter-strut diameter, which permitted successful guidewire passage from the occluded distal LAD segment (abluminal side of a previously placed mid LAD-to-diagonal stent) into the proximal LAD. In addition, the use of IVUS imaging of the mid LAD stent over an antegrade wire was important in our case as in others15 to verify an intraluminal position of the retrograde wire. In conclusion, by using the retrograde CTO technique with adjunctive balloon expansion of a previously placed stent and IVUS guidance, we were able to achieve procedural success in this challenging case. From the *Division of Cardiology, California Pacific Medical Center, San Francisco, California. #Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Kanagawa, Japan. The authors report no conflicts of interest regarding the content herein. Manuscript submitted July 6, 2009, provisional acceptance given July 30, 2009, final version accepted August 3, 2009. Address for correspondence: Xiushui Ren, MD, Division of Cardiology, California Pacific Medical Center, 2333 Buchanan Street, Room 1-109, San Francisco, CA 94115. E-mail: xiushui@yahoo.com2. Kinoshita I, Katoh O, Nariyama J, et al. Coronary angioplasty of chronic total occlusions with bridging collateral vessels: Immediate and follow-up outcome from a large single-center experience. J Am Coll Cardiol 1995;26:409‚Äì415.
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