The Twin-Pass Dual Access Catheter for Assessment of the No-Reflow Phenomenon

ABSTRACT: The absence of antegrade flow in a coronary artery during an intervention is an ominous finding requiring diagnosis of the underlying cause and rapid treatment to limit myocardial necrosis. The Twin-Pass dual access catheter allows for distal coronary contrast injection without loss of wire position. The aim of this analysis was to determine the opacification and flow features of patients with abrupt arrest of antegrade flow to determine the underlying pathology. Methods. Coronary angiograms of patients with abrupt arrest of antegrade flow during an intervention that underwent distal vessel contrast injection with the Twin-Pass catheter were retrospectively analyzed for five features: antegrade flow, retrograde flow, myocardial blush, presence of contrast stasis in the vessel wall and evidence of an intraluminal filling defect. The features were then correlated with the underlying pathological process and treatment. Results. Seven patients underwent distal contrast injections. Four specific pathological processes were identified: presence of a proximal occlusive lesion; no-reflow due to distal vascular bed dysfunction; long dissection of the vessel with the distal wire residing in the true lumen or alternatively in the dissection plane. The patients were treated according to the pathology with stenting, intracoronary adenosine or wire repositioning. Conclusions. Distal vessel contrast injection using the Twin-Pass catheter in the presence of no-reflow is a simple and rapid technique that allows for the definition of four distinct clinical scenarios. This allows for rapid treatment of the underlying pathological process, reducing the period of end-organ ischemia, limiting occasional unnecessary stent deployment and further improving procedural results. J INVASIVE CARDIOL 2010;22:125–129 Key words: antegrade flow, retrograde flow, myocardial blush, contrast stasis The disappearance of distal vessel flow during percutaneous coronary intervention (PCI) is an ominous phenomenon. This may occur at the commencement of the procedure following wire passage, or following ballooning or stent deployment. A number of pathological processes can result in this phenomenon.1,2 A successful conclusion to the intervention is dependent upon the correct diagnosis and the institution of its appropriate treatment rapidly enough to limit the distal organ ischemia that results from the lack of flow. The Twin-Pass Catheter (Vascular Solutions, Inc., Minneapolis, Minnesota) is a double lumen catheter that allows for wire exchange and administration of solutions through a small catheter lumen to facilitate diagnosis and treatment.3 It offers the specific advantage of allowing distal vessel contrast administration as well as drug administration to various sites in the distal vessel without the loss of wire position. The aim of this study was to determine the defining features between different pathological processes that underlie the absence of distal visualization that occurs during percutaneous intervention by taking advantage of the Twin-Pass catheter’s features.

Methods

Retrospective assessment was performed in 7 consecutive cases of abrupt arrest of antegrade flow that occurred following the passage of a coronary wire, balloon inflation or stent deployment when distal contrast injection was performed for clinical indications using a novel double lumen catheter, the Twin-Pass Dual Access Catheter. Device description. The Twin-Pass dual access catheter is a hydrophilically coated, dual lumen catheter designed for use in the arterial vasculature. The catheter provides support for 0.014 inch x 0.36 mm guidewires during interventional procedures, and the dual lumen design allows for the delivery of a second guidewire into the distal vasculature while leaving the initial guidewire in place. The distal exit port is from a 20 cm long monorail wire lumen, while the proximal exit port emanates from a lumen extending back to the hub in an “over-the-wire” configuration. The Twin-Pass catheter comes with a stiffening mandrel to provide support and pushability during catheter insertion. It is compatible with a minimum guide catheter internal diameter of 0.058 inch x 1.47 mm. The Twin-Pass catheter has a radiopaque marker band located approximately 1mm proximal to the distal tip and a second radiopaque marker band located at the through-lumen exit port 10 mm proximal to the distal tip (Figure 1). The crossing profile of the distal tip is Results The demographic details of the patients are presented in Table 1. Procedural details are presented in Table 2. Distal vessel contrast injection was successful and diagnostic in all cases. Four specific pathological processes were apparent in these patients. 1. Presence of a proximal occlusive lesion: In these cases a thrombus, intimal flap or distal stent edge dissection was apparent. The initial distal injection demonstrated brisk antegrade flow in the distal vessel with excellent runoff to the distal bed, marked myocardial blush and no retrograde flow. Stepwise injections demonstrated the flap or thrombus at the occlusive site. In these cases, the lesions were treated with thrombus extraction (if appropriate) and lesion stenting with good result (Figures 2A and B). 2. No reflow due to distal vascular bed dysfunction: These cases were predominantly associated with no reflow post-balloon inflation or stenting in the presence of a significant thrombus load. In such cases the distal injection results in almost no antegrade flow, an absence of myocardial blush, marked retrograde flow on occasion even with spill into the aorta and an absence of any occlusive proximal lesion (Figure 3). 3. Long spiral dissection of the vessel with the distal wire residing in the true lumen: Distal injection is associated with normal antegrade flow, good myocardial blush and no or minimal retrograde filling. The stepwise proximal injections reveal the dissection planes with minimal contrast stasis in the vessel wall. The inflow and outflow of the dissection can also be detected (Figures 4A and B). 4. Long dissection of the vessel with the distal wire residing in the dissection plane: In this instance, there was an absence of antegrade flow, minimal retrograde flow, no myocardial blush and obvious stasis within the vessel wall (Figure 5). The treatment for each of the cases was on the basis of the findings during intracoronary injections. In the presence of a localized occlusive lesion, this was stented with restoration of excellent flow. In the presence of distal no-reflow, intracoronary adenosine was administered, in two cases via the Twin-Pass catheter itself with restoration of antegrade flow. In the presence of a long dissection with the distal wire in the true lumen, dissection long stenting was performed, and when the wire was demonstrated not to be in the true lumen, this wire position was abandoned and attempts to wire the true lumen were made.

Discussion

The day-to-day practice of endovascular interventionists is almost entirely dependent upon adequate vessel opacification using radiographic contrast material. The intraprocedural finding of no distal flow is ominous, not only because of the apparent end-organ ischemia, but also due to our lack of ability to confidently define the pathological process underlying this phenomenon. As such, our approach is that of stepwise treatment depending upon the clinical scenario, including ensuring there is no local occlusion, administration of vasodilators, particularly in the presence of a large thrombus load or following intervention to a vein graft, and ballooning and stenting along the length of the occlusion in the hope of covering an unseen dissection. The Twin-Pass catheter allows for the distal administration of medication to the distal bed without the risk of losing wire position in the questionable presence of a distal dissection. This, therefore, can be used for diagnostic purposes to clearly delineate the underlying pathological process. Alternative techniques are available, but each has limitations. Specifically, over-the-wire balloons or microcatheters can be advanced beyond the lesion, the 300 cm wire retracted and distal injection performed. Here, the major limitation is the use of long wires and the inability to maintain distal wire position, particularly in the presence of a dissection. Another option is the use of an aspiration catheter. Here, the limitation of a large catheter made to extract large thrombus load with the potential to worsen dissection or catch on stent struts would prevent its use for this application. Intravascular ultrasound offers an option to determine the presence of a dissection or thrombus at the flow arrest site. It is unable to determine the distal runoff of the vessel and the presence or absence of a very distal thrombus. Furthermore, its introduction into a dissection plane may well worsen the pathology. Finally, off-label use of a monorail balloon with multiple small punctures in the balloon will allow for distal contrast injection through the balloon lumen if the injectate is significantly diluted contrast. This, of course, is an innovative solution in the absence of a dedicated catheter such as the Twin-Pass that allows for a greater flow rate, improved opacification and no risk of embolization of balloon material. The observation of five features during distal vessel injection with stepwise proximal injections allowed for the delineation of four distinct clinical scenarios based upon distinct pathological processes. The presence of proximal flow obstruction due to a flap or a thrombus leaves the distal bed with marked vasodilation, such that distal contrast administration results in brisk antegrade flow and marked myocardial blush. The classic no-reflow phenomenon is secondary to plugging of the distal bed by embolic debris associated with endothelial dysfunction, leukocyte activation and cellular and intracellular swelling following localized ischemia.4 Functionally, the result is the inability of the blood to flow forward into the affected arterioles and capillaries with resultant stasis in the main epicardial vessel. Distal contrast injection in such an instance will not result in antegrade flow or myocardial blush, however, depending on the vessel size and the amount and rate of injection, marked retrograde flow will be noted even back to the vessel ostium and aorta, or alternatively, to unaffected side branches. Distal injections into dissected vessels will demonstrate the different lumens or the dissection plane, depending upon the site of the distal wire.

Conclusion

Distal vessel contrast injections using the novel Twin-Pass catheter in the presence of no-reflow is a simple and rapid technique that allows for the definition of four distinct clinical scenarios: proximal occlusive lesions, distal embolization and distal dissection with the distal wire either in or out of the true lumen. Rapid diagnosis of each of these scenarios allows for the endovascular interventionist to treat the underlying pathological process rapidly and effectively, reducing the period of end-organ ischemia, limiting occasional unnecessary stent deployment and further improving procedural results.

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From the Department of Cardiology of the Shaare Zedek Medical Center, Jerusalem. The authors report no financial relationships or conflicts of interest regarding the content herein. Manuscript submitted November 5, 2009, provisional acceptance given December 1, 2009, final version accepted December 21, 2009. Address for correspondence: David Meerkin, MBBS, Director of Experimental Cardiology, Department of Cardiology, Shaare Zedek Medical Center, POB 3235, Jerusalem 91031, Israel. E-mail: meerkin@szmc.org.il

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References

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