Abstract: Subintimal dissection and reentry techniques are widely used in chronic total occlusion (CTO) interventions; however, inability to reenter into the distal true lumen is a common cause of failure. In some patients, subintimal hematoma may develop, compressing the lumen and hindering reentry. We describe 3 CTO cases in which the distal vessel could not be visualized after subintimal crossing, in spite of attempts to decompress the subintimal hematoma. Bidirectional “blind” puncture was performed with the Stingray wire through both ports of the Stingray balloon, followed by exchange of the Stingray wire for a Pilot 200 guidewire (the “double-blind stick-and-swap” technique) achieving distal true lumen reentry.
J INVASIVE CARDIOL 2015;27(9):E199-E202
Key words: chronic total occlusion, dissection and reentry, stick-and-swap
Dissection and reentry techniques have revolutionized chronic total occlusion (CTO) interventions and have significantly contributed to the increase of CTO percutaneous coronary intervention (PCI) success rates.1-4 Dissection can be achieved with a knuckle wire or CrossBoss catheter (Boston Scientific).5-7 Reentry can be achieved with various wire-based techniques, or with the Stingray balloon and guidewire (Boston Scientific).8,9 The Stingray balloon is inflated at low pressure (2-4 atm) and the Stingray wire is advanced through the port facing the distal true lumen under fluoroscopic guidance. Sometimes (especially when knuckle wires are used for dissection), subintimal hematoma may form, resulting in distal true lumen compression, which hinders reentry. We describe a novel technique for overcoming this challenge, the “double-blind stick-and-swap” technique.
A 64-year-old man with a history of type-2 diabetes mellitus, hypertension, hyperlipidemia, prior myocardial infarction, and prior coronary artery bypass graft (CABG) surgery presented with stable angina and was referred for cardiac catheterization. Diagnostic angiography revealed a calcified left main artery with a 90% stenosis and two CTOs located in the proximal left anterior descending (LAD) artery and proximal left circumflex (LCX) artery (Figure 1A). Bypass graft angiography revealed occlusion of the left internal mammary artery (LIMA) graft that supplied the area distal to the proximal LAD-CTO and moderate stenoses in the saphenous vein grafts (SVGs) that supplied the second obtuse marginal branch and the right posterior descending artery (PDA). The LAD distal to the CTO filled via ipsilateral bridging collaterals. Viability was demonstrated by magnetic resonance imaging and the patient was referred for multivessel PCI.
The left main was engaged with an 8 Fr, 3.5 XB guide. Injection of the LIMA and SVG to PDA grafts failed to demonstrate collateral flow to the distal LAD. Initial attempts to cross the proximal LAD-CTO using Fielder XT (Asahi Intecc), Pilot 200 (Abbott Vascular), and Confianza Pro 12 (Asahi Intecc) wires through a Corsair catheter (Asahi Intecc) in an antegrade fashion were unsuccessful. Antegrade dissection was then performed with a CrossBoss catheter, which crossed subintimally into the mid LAD (Figure 1B). The Stingray balloon and guidewire were used for reentry (Figure 1C), yet the mid LAD could not be visualized (likely due to subintimal hematoma). Aspiration through the Stingray balloon did not improve visualization, hence a “double-blind” puncture was performed by advancing the Stingray wire though both side ports of the Stingray balloon. The Stingray wire was exchanged for a Pilot 200 guidewire that successfully reentered the distal true lumen (Figure 1D). The CTO was successfully stented with three everolimus-eluting stents (Figure 1E), providing an excellent final angiographic result (Figure 1F). During the same procedure, successful PCI of the LCX-CTO and left main artery was also performed. A total of 415 mL of contrast were used for the procedure and Air Kerma (AK) dose was 6.1 Gray. The patient tolerated the procedure well and was transferred to the recovery room in stable condition. During 12 months of follow-up, he remained angina free.
An 84-year-old man with hypertension, hyperlipidemia, prior CABG, and prior PCI of a SVG to the first diagonal branch (D1), followed by repeat PCI of the SVG to D1 for in-stent restenosis, presented with dyspnea on exertion. Diagnostic angiography showed an 80% stenosis in the mid LAD, 90% stenosis in both the D1 and obtuse marginal branch (OM1), and a 20 mm CTO in the proximal RCA (Figure 2A). The distal RCA filled via epicardial collaterals from the LCX. The mid LAD, D1, and OM1 were bypassed by patent SVGs; however, the SVG to the right PDA was occluded.
PCI of the RCA-CTO was attempted. Heparin was used for anticoagulation. The RCA was engaged with an 8 Fr AL 0.75 guide and the left main artery with an 8 Fr EBU 3.75 guide. Attempts for antegrade lesion crossing using a MultiCross catheter (Roxwood Medical), a Fielder XT wire, and a CrossBoss catheter were unsuccessful (Figure 2B). A knuckle with the Fielder XT wire was advanced to the distal RCA and exchanged for a Stingray balloon (Figure 2C). Visualization of the distal RCA was poor, likely because of subintimal hematoma formation. The double-blind stick-and-swap technique was successfully performed (Figures 2D and 2E), as described in Case #1, achieving distal true lumen reentry, as confirmed with contralateral injection. The Pilot guidewire was exchanged for a workhorse guidewire that was advanced into the SVG to PDA stump. After placement of three everolimus-eluting stents, final angiography revealed well-apposed and expanded stents, with TIMI-3 flow and no residual stenosis (Figure 2F). The procedure required 360 mL of contrast and an AK dose of 2.9 Gray. The patient’s symptoms subsequently resolved.
A 66-year-old man with no prior cardiac history presented with atypical chest pain and a positive stress test. The patient was referred for diagnostic angiography, which revealed CTO of the mid RCA and mid LAD (Figure 3A). The LAD distal to the CTO filled via epicardial collaterals from the diagonal branch and the RCA via epicardial collaterals from the LCX. He was referred for elective CTO-PCI. Both CTOs were treated during the same procedure. The RCA was engaged with an 8 Fr AL1 guide catheter and the left main artery was engaged with a 6 Fr Ikari Left guide for contralateral injection. A Pilot 200 guidewire over a Finecross microcatheter (Terumo Corporation) crossed the RCA-CTO into the subintimal space (Figure 3B). The distal RCA was poorly visualized, likely due to a combination of subintimal hematoma and diffuse disease. Reentry into the distal true lumen was achieved with a Stingray reentry catheter using the double-blind stick-and-swap technique (Figures 3C and 3D). Final angiographic result was acceptable, with <20% residual stenosis and TIMI-3 flow (Figure 3E). Total contrast and AK use were 450 mL and 2.4 Gray, respectively. Following successful treatment of the LAD-CTO, the patient was discharged in stable condition. He had complete angina resolution.
Our case report demonstrates the utility of the novel double-blind stick-and-swap technique when distal true lumen reentry is challenging.
Use of the Stingray system for reentry can be hindered by: (1) inability to advance the Stingray balloon to the reentry zone; (2) poor visualization of the Stingray balloon and the distal true lumen; (3) inability to enter a diffusely diseased distal vessel; (4) compression of the distal true lumen by a subintimal hematoma; (5) severe distal vessel calcification; and (6) occlusion of a side branch at the distal cap.10
Visualizing the distal target vessel in relation to the Stingray balloon is important to maximize the chances for successful reentry, as it provides a target for the Stingray guidewire. Meticulous preparation of the Stingray balloon and use of magnified views can assist with visualization of the Stingray system. A common cause for poor distal vessel visualization is compression of the distal true lumen by subintimal hematoma. This is more likely to occur when dissection is performed with a knuckle wire, which is why use of the CrossBoss catheter is favored (at least for the final dissection segment) to minimize the extent of the subintimal dissection.
There are several solutions for poor visualization of the reentry zone of the target vessel, such as use of the subintimal transcatheter withdrawal (STRAW) technique, during which suction is applied through the Stingray balloon or through a separate over-the-wire balloon to aspirate the hematoma and reexpand the compressed vessel. Another technique is “bob sledding,” in which the Stingray balloon is advanced to a different reentry zone with a larger and more visible target vessel. A third technique is the “stick-and-swap,” in which the subintimal space is initially punctured with the Stingray wire, which is advanced though the lumen against the opposite wall.11 The Stingray wire is then removed and a Pilot 200 guidewire is advanced through the same exit port, a subintimal exit point to successfully track into the distal true lumen (Figure 2). Fourth, retrograde crossing can be performed if antegrade reentry attempts fail.12
The double-blind stick-and-swap technique is a variation of the stick-and-swap technique. Puncture is performed with the Stingray wire through both side ports of the Stingray balloon to create a “pathway” toward the true lumen. A stiff, polymer-jacketed guidewire is subsequently advanced through both side ports of the Stingray balloon until distal true lumen reentry is achieved, as confirmed by contralateral injection. Advantages of this technique are ease of use, utilization of readily available equipment, and speed, as this approach can be very efficient. There is a theoretical risk of perforation when wires are advanced through the Stingray balloon port facing the adventitia; however, the risk is likely very small, given that only wires are advanced and not balloons or microcatheters.13 As with all new techniques, continued evaluation is needed to understand its advantages and shortcomings. Finally, the double-blind stick-and-swap technique may not always be successful, and in some cases alternative crossing techniques such as the retrograde approach need to be used, as described above.12
In summary, the double-blind stick-and-swap method is a novel technique that can greatly facilitate reentry into the distal true lumen when visualization of the distal vessel is compromised.
- Whitlow PL, Burke MN, Lombardi WL, et al. Use of a novel crossing and reentry system in coronary chronic total occlusions that have failed standard crossing techniques: results of the FAST-CTOs (Facilitated Antegrade Steering Technique in Chronic Total Occlusions) trial. JACC Cardiovasc Interv. 2012;5:393-401.
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- Martinez-Rumayor AA, Banerjee S, Brilakis ES. Knuckle wire and stingray balloon for recrossing a coronary dissection after loss of guidewire position. JACC Cardiovasc Interv. 2012;5:e31-e32.
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- Mogabgab O, Patel VG, Michael TT, et al. Long-term outcomes with use of the CrossBoss and stingray coronary CTO crossing and reentry devices. J Invasive Cardiol. 2013;25:579-585.
- Brilakis ES. Manual of Chronic Total Occlusion Interventions. A Step-By-Step Approach. Elsevier: Waltham, Massachusetts; 2013.
- Brilakis ES, Grantham JA, Rinfret S, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5:367-379.
- Latif F, Brilakis ES, Exaire JE. Retrograde approach to successfully treat antegrade failure due to subintimal hematoma of a right coronary artery chronic total occlusion. Interv Cardiol. 2015;7:229-233.
- Brilakis ES, Karmpaliotis D, Patel V, Banerjee S. Complications of chronic total occlusion angioplasty. Interv Cardiol Clin. 2012;1:373-389.
From the Veterans Affairs North Texas Health Care System, Dallas, Texas, and the University of Texas Southwestern Medical Center, Dallas, Texas.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Brilakis reports consulting fees/speaker honoraria from St. Jude Medical, Boston Scientific, Asahi Intecc, Janssen, Abbott Vascular, Elsevier, Sanofi, and Terumo; research support from Guerbet; spouse is an employee of Medtronic. Dr Kotsia and Dr Christopoulos report no conflicts of interest regarding the content herein.
Manuscript submitted August 12, 2014, provisional acceptance given October 6, 2014, final version accepted October 8, 2014.
Address for correspondence: Emmanouil S. Brilakis, MD, PhD, VA North Texas Health Care System, Cardiology, 4500 South Lancaster Road, Dallas, TX 75216. Email: firstname.lastname@example.org