A growing body of evidence suggests a prognostic and symptomatic benefit of reopening coronary chronic total occlusions (CTOs).1 However, percutaneous revascularization of CTOs remains a challenge for the interventional cardiologist. The main limitations of CTO angioplasty were considered to be, on the one hand, difficulty in crossing and, on the other hand, poor angiographic and clinical outcome when using a bare-metal stent (BMS) after occlusion crossing and balloon dilatation.2 The introduction of the drug-eluting stent (DES) has clearly reduced angiographic restenosis and target lesion revascularization rates compared to BMS in the treatment of CTOs, virtually eliminating the limitations of poor angiographic and clinical outcomes observed with BMS.3–5 However, crossing the occlusion is still a main cause of failure, and despite remarkable technical progress in the percutaneous management of CTOs, no device has been shown to be successful in all cases. Operator experience and specific tips and tricks for more difficult cases are needed to achieve procedural success in the majority of situations. We describe a case of successful reopening of a chronically occluded right coronary artery (RCA) using a retrograde wire as a landmark of the true lumen and a novel penetration device to facilitate balloon and stent deployment. Case Report. A 71-year-old male was admitted to our hospital because of angina on minimal effort. He was a noninsulin-dependent diabetic, with a previous history of inferior myocardial infarction in 1996. After the infarction, the patient developed angina on effort, which was treated by medical therapy including aspirin, beta-blockers and an ace-inhibitor. He remained asymptomatic on medical therapy up to the current admission. A myocardial perfusion thallium scan showed reversible ischemia in the inferior (perinecrotic zone) and lateral walls. Coronary angiography was then performed on June 30, 2005, and showed proximal occlusion of the RCA (Figure 1) and of the left circumflex artery (LCx) (Figure 2). The left anterior descending artery (LAD) was free of significant disease, and there was good collateral flow (Rentrop 3) to the RCA from the septal branches of the LAD (Figure 2). Left ventriculography showed posterobasal akinesia, with an ejection fraction of nearly 50%. In view of the poor response to medical therapy and considering the results of the perfusion scan, we decided to attempt to reopen both occlusions in two separate sessions, beginning with the RCA on October 6, 2005. A bilateral femoral approach was used, inserting a 7 Fr sheath in the right groin and a 6 Fr sheath in the left groin. The right side was used for RCA cannulation with a 7 Fr guiding catheter JR4SH (Vista Brite Tip®, Cordis Corp., Miami, Florida), whereas the left side was used for left coronary cannulation with a diagnostic JL4 (Cordis). Bilateral injection demonstrated occlusion of the proximal part of the RCA, with good collateral opacification up to the distal end of the occlusion (Figure 3). Antegrade reopening was tried using a 9 g Conquest Pro wire (Asahi/Abbott Laboratories) supported by a soft tip microcatheter (Masters, Asahi/Abbott Laboratories). The penetrating wire strategy6 was used under frequent bilateral contrast injections, but unfortunately, the wire went into the false lumen (Figure 4). At this point, we decided to try the parallel wire technique, leaving the first wire in the false lumen and using a 12 g Conquest Pro wire supported by another microcatheter (Navicath, Terumo Medical Corp., Somerset, New Jersey) to find the true lumen (the first microcatheter was pulled back to facilitate advancement of the second microcatheter). Again, the new wire entered the false lumen, but in a different manner than the first wire. Considering the optimal collateral channels from the LAD to the RCA, we attempted a retrograde approach. A 6 Fr guiding catheter XB 3.5 (Vista Brite Tip) engaged the left coronary ostium. A hydrophilic-coated floppy wire (Runthrough, Terumo), supported by a 1.5 x 20 mm over-the-wire balloon (Maverick®, Boston Scientific Corp., Natick, Massachusetts), was passed in a septal branch which appeared to be directly connected to the posterior descending artery, and eventually, we were able to direct the wire up to the distal end of the occlusion (Figure 5). We were not able to advance the over-the-wire balloon retrogradely through the septal branches into the RCA. However, the retrograde wire clearly showed the position of the true lumen. Both the 9 g and 12 g Conquest Pro wires were located in the false lumen outside the true lumen of mid-RCA. Eventually, using the 12 g Conquest Pro wire supported by the microcatheter, we were able to get into the true lumen using an antegrade approach (Figure 6). At this point, due to the inability to cross the occlusion with the microcatheter or a 1.5 x 20 mm monorail balloon (Maverick), we used a novel penetration catheter (Figure 7), which enabled subsequent balloon passage and dilatation (1.5 x 20 mm and 2.0 x 20 mm, Maverick monorail balloons). The RCA was then stented with several drug-eluting stents (Cypher™ select stents 2.5 x 33 mm, 3 x 33 mm, 3 x 28 mm from distal to proximal, Cordis Corp., Miami, Florida), and the final angiographic result was good (TIMI 3 flow, no residual stenosis) (Figure 8). The patient was discharged the following day without any complications or periprocedural myocardial necrosis. Discussion. We describe a case of the successful reopening of a chronically occluded RCA in which success was ultimately due to the use of a retrograde landmark wire and a novel penetration catheter. CTO angioplasty procedures are probably the most challenging cases in the field of coronary intervention, and the presence of CTOs has been recently shown to be the strongest contraindication for percutaneous coronary intervention.7 DES utilization for CTO has dramatically reduced the occurrence of restenosis and reocclusion.3–5 However, crossing the CTO with a wire and subsequently with a balloon are still causes of failure. In this case report we faced both problems which were solved by using appropriate devices and specific “tricks”. New devices (Safe-Cross™, IntraLuminal Therapeutics, Inc., Carlsbad, California, and the Frontrunner XP® CTO Catheter, LuMend, J&J Health Care Systems, Inc., Piscataway, New Jersey) have been developed to improve crossing capability, but recently-reported success rates did not exceed 60% of cases.8–9 The combination of dedicated wires for CTO and the retrograde landmark wire in the true lumen allowed us to accurately cross the occlusion. Another possibility when the wire frequently enters the false lumen despite the parallel wire technique is to employ the IVUS-guided re-entry technique. An IVUS catheter positioned in the false lumen allows visualization of the true lumen and redirection of the wire in the true lumen.10 The second problem we encountered with our patient was the inability to cross the occlusion with either the microcatheter or the small balloon. We solved this problem with a new penetration catheter, the Tornus device, which will often cross the occlusion when a microcatheter or a balloon fail and creates a channel for subsequent dilatation, as was recently demonstrated by Tsuchikane and colleagues.11 The Tornus is a novel penetration over-the-wire catheter with excellent flexibility and torqueability. It is made of 8 stainless wires stranded in the coil of the shaft with a right-handed lay (clockwise). It can cross through a severe stenosis or occlusion easily with counter-clockwise rotation along the guidewire because the shaft is stranded clockwise. Another possibility in situations like this is to use a laser wire,12 or if the microcatheter crosses the occlusion, to exchange it for a RotaWire™ (Boston Scientific) and then ablate the lesion with a Rotablator® catheter (Boston Scientific).13 In conclusion, achieving success in this complex CTO case required dedicated devices and knowledge of specific techniques and “tricks”. CTO reopening strategies must become more widely practiced in the interventional community and industry must continue its efforts to develop new CTO-dedicated devices. Acknowledgement. We wish to thank Mrs. Rainswell for grammatical revision of this manuscript.
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