ABSTRACT: Percutaneous coronary intervention (PCI) was performed for a chronic total occlusion (CTO) of the right coronary artery (RCA) in a 77-year-old male patient. A guidewire could not be passed through the vessel using the antegrade approach, so we tried the retrograde approach via a collateral septal channel. A Fielder FC guidewire (Asahi Intecc Co. Ltd., Aichi, Japan) was passed through the septal channel, and a Corsair catheter (Asahi Intecc) was advanced to the distal side of the CTO in the RCA. However, the guidewire could not be advanced from the false lumen to the true lumen using the kissing-wire technique (KWT) or the reverse controlled antegrade retrograde tracking (CART) technique. Therefore, we retracted the Corsair channel dilator for a #4PD and tried to advance the antegrade Conquest Pro guidewire (Asahi Intecc) from a straight subintimal site into the retrograde channel dilator catheter. After several attempts, the antegrade Conquest guidewire successfully entered the retrograde channel dilator catheter. Subsequently, a Cypher stent (Cordis Corp., Miami Lakes, Florida) was successfully placed. The “rendezvous in coronary” technique was useful for this CTO patient, in whom it was difficult to advance a guidewire into the true lumen by the KWT and CART techniques during the retrograde approach.
J INVASIVE CARDIOL 2010;22:E179–E182
Key words: PCI, CTO, retrograde approach
Percutaneous coronary intervention (PCI) for the treatment of chronic total occlusion (CTO) has advanced remarkably in recent years. Improvement of various techniques and the advent of new devices have dramatically improved the initial outcome,1,2 and a better long-term prognosis has also been verified.3 Recently, the retrograde approach has become popular, in which a guidewire is advanced to the distal side of a CTO via a contralateral collateral pathway.4 The retrograde approach was originally reported with a bypass graft being employed for passage of the guidewire,5 but a native channel is generally used for this approach at present. However, it is not always easy to advance a guidewire from the false lumen to the true lumen of the CTO after the wire has been passed through a collateral channel by the retrograde approach. To handle such cases, the CART and reverse CART techniques have been proposed.6,7 Recently, we experienced a case of the retrograde approach in which the “rendezvous in coronary” technique was successful after failure to advance a guidewire from the false lumen to the true lumen by the reverse CART technique. Case Report. A 77-year-old male presented to our hospital complaining of chest tightness. He had a 10-year history of hypertension and a Y graft for aortic aneurysm (October 2009). He reported no contributory family history. He presented to our emergency department after experiencing a loss of consciousness for about 5 minutes. Echocardiography revealed abnormalities of the inferior wall region. Cardiac catheterization was performed a month later, revealing a 90% of the #2 and a CTO of the #3 in the right coronary artery (RCA). Five months later, we decided to stent the RCA. The patient was conscious, his blood pressure was 140/80 mmHg, his pulse was 90 beats/min (regular), his heart and breath sounds were normal, and there were no abnormalities of the abdomen or limbs. Laboratory tests revealed the following: WBC 6.29 × 103/µl, RBC 453 × 104/µl, Hb 13.7 g/dl, Plt 22.4 × 104/µl, UN 11.9 mg/dl, Cr 0.91 mg/dl, Na 142 mEq/l, K 4.1 mEq/l, Cl 105 mEq/l, TP 7.5 g/dl, T-B 0.4 mg/dl, AST 22 U/l, ALT 15 U/l, LAD 228 U/l, and CK 51 U/l. The electrocardiogram (ECG) showed sinus rhythm with Q waves in leads II, III, and aVF. On coronary angiography (Figure 1), the RCA showed 90% stenosis at #2 and complete obstruction from #3. There was good collateral flow (Rentrop Grade III) from the left anterior descending coronary artery (LAD) through septal channels. The length of the CTO was about 50 mm. Left ventriculography revealed a decrease in movement at the inferior-wall region. PCI procedure. From the beginning, the retrograde approach was considered. First, 7 Fr sheaths were inserted into the bilateral femoral arteries, and a 7 Fr AL0.75 guide catheter (Launcher, Medtronic Inc., Minneapolis, Minnesota) was inserted into the RCA while a 7 Fr 90 cm EBU guide catheter (Launcher, Medtronic) was inserted into the left coronary artery. Next, a 3.0 x 18 mm Cypher stent (Cordis Corp., Miami Lakes, Florida) was placed at the mid-portion of the RCA stenosis (#2). Subsequently, a Conquest Pro guidewire (Asahi Intecc Co., Aichi, Japan) inside a microcatheter (Finecross, Terumo Co., Tokyo, Japan) was employed to attempt antegrade insertion into the entry point of the CTO (#3). However, the proximal cap of the CTO was so hard that penetration was difficult and the catheter deviated into a side branch (Figure 2). Therefore, we tried the retrograde approach via a contralateral septal collateral channel. We used a Fielder FC guidewire (Asahi Intecc) in a Corsair channel dilator (Asahi Intecc) to attempt penetration of the collateral pathway. The septal channel showed marked curvature halfway, but we were able to successfully navigate it by inserting the guidewire at a 90º angle laterally (Figure 3). Subsequently, a channel dilator catheter was guided to the distal side of the CTO in the RCA, and the kissing wire technique (KWT” was attempted by using the antegrade Conquest Pro guidewire and a retrograde Miracle 6g guidewire (Asahi Intecc). However, both guidewires deviated into the subintimal space, and penetration through the CTO failed. Since the CTO could not be penetrated after replacing the retrograde guidewire with a Conquest Pro guidewire, we next tried the reverse CART technique with a Firestar 2.5 mm balloon (Cordis). Unfortunately, advancement from the false lumen to the true lumen could not be achieved after several attempts at the reverse CART technique (Figure 4). Therefore, we retracted the Channel dilator catheter to the #4PD, and tried to insert the antegrade Conquest pro guidewire, which was located at a subintimal position in a straight channel, into the retrograde Channel dilator catheter. After several attempts, the antegrade Conquest guidewire entered into the retrograde Channel dilator catheter and was pulled through (Figure 5). Then, Firestar balloon catheters (1.5 and 2.5 mm) were used with the Conquest Pro guidewire to expand the CTO, after which two Cypher stents (2.5 × 23 mm and 2.5 × 28 mm) were successfully placed (Figure 6). A good outcome was obtained, and the patient is currently an outpatient of our hospital without chest pain. Discussion. PCI for the treatment of CTO has shown remarkable advances in recent years. Improvement of various techniques and the development of new devices have led to a dramatically better initial outcome.1,2 The retrograde approach involves crossing a guidewire from the distal side of the CTO via a contralateral collateral, and it has become popular of late.4 Di Mario et al used the retrograde approach for 17 patients up until 2007, with a success rate of 76.5%.8 A report from the Toyohashi Heart Center describes a guidewire success rate of 75.2% and a procedural success rate of 65.6% with the retrograde approach in 157 patients,9 while Saito et al reported a guidewire success rate of 82% and a procedural success rate of 84% in 45 patients.7 Difficulties with the retrograde approach include problems with advancing the guidewire through the collateral channel, as well as subsequently achieving penetration of the guidewire and devices within the CTO. In the case reported here, we encountered difficulty in entering the CTO with the guidewire after it had crossed the collateral channel. We attempted the reverse CART technique, but it failed. Therefore, we advanced the antegrade guidewire into a retrograde Corsair catheter to achieve communication from the false lumen to the true lumen. This may be the first case in which the “rendezvous in coronary” technique was used with a retrograde approach. Usually, a retrograde guidewire that has entered the occluded vessel is used to cross the CTO. When this fails, the guidewire is replaced with a slightly firmer guidewire such as one from the Miracle series, and retrograde crossing of the CTO is tried again, or the kissing-wire technique is attempted with an antegrade guidewire being simultaneously employed. When the retrograde guidewire and a microcatheter can be inserted into the contralateral guide catheter, the procedure can be performed successfully with the so-called “retrograde wire-crossing technique”, in which the initial guidewire is replaced with a 3 mm guidewire and is pulled out from the contralateral sheath.10 When the retrograde guidewire enters a false lumen and penetration of a CTO is difficult, the CART6 and reverse CART7 techniques are widely used. Surmely et al6 report on 10 CTO patients who were successfully treated with the CART technique. To perform the CART technique, a balloon is inserted retrogradely along a retrograde guidewire that lies in a false lumen and is inflated to expand the false lumen, after which an antegrade guidewire is advanced to the true lumen peripheral to the CTO via the expanded false lumen. Recently, the reverse CART technique has been proposed, in which a balloon is inserted via the antegrade approach to expand the false lumen, after which a retrograde guidewire is advanced.7 The reverse CART technique is simple, but requires caution because it can sometimes lead to severe dissection.11 In some cases, the wire cannot be advanced from a false lumen to the true lumen, even after trying these approaches, forcing us to try other methods. As one possibility, Wu et al12 have suggested a confluent balloon technique which involves two balloons being expanded simultaneously in cases where a guidewire cannot be advanced by either the CART or reverse CART technique. Ge et al13 have proposed a reverse wire-trapping technique, in which a retrograde guidewire is caught by an antegrade snare. The rendezvous technique was originally reported by Kim and Mitsudo et al.14 They described a method in which microcatheters were aligned in a guide catheter, after which an antegrade guidewire was pulled into a retrograde microcatheter. Wu et al15 reported on a patient in whom a left main trunk dissection occurred during the CART technique, after which a retrograde guidewire was advanced into an antegrade balloon catheter for bailout. In the present case, the guidewire was intentionally pulled back into the coronary artery to perform the rendezvous technique. The reasons for success in the present case may include the technique being used in a distal coronary artery so that the Corsair catheter from the contralateral side was relatively stable and readily visible. Another reason the ease in inserting the guidewire into the Corsair catheter was that we used a Conquest guidewire with a tapered hard tip. Conclusion. We report that a good outcome may be obtained by the rendezvous in coronary technique in a case of CTO where the retrograde approach (reverse CART technique) has failed to achieve reentry of a retrograde guidewire from the false lumen into the true lumen. This result suggests that the rendezvous in coronary technique may be useful for patients in whom the CART and reverse CART techniques are difficult.
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From the Division of Cardiology, Saiseikai Yokohama-City Eastern Hospital. The authors report no conflicts of interest regarding the content herein. Manuscript submitted February 1, 2010, provisional acceptance given February 15, 3010. and accepted February 19, 2010. Address for correspondence: Dr. Toshiya Muramatsu, Saiseikai Yokohama-city Eastern Hospital, 3－6-1 Shimosueyoshi, Tsurumi, Yokohama-shi, Kanagawa 23－0012 Japan. E-mail: firstname.lastname@example.org