The success rates of percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs) have improved with advances in devices, equipment and expertise, in- cluding the use of the retrograde approach. CTO with bifurcation lesions is a special overlapping subset of CTO and bifurcated coronary artery disease (CAD) management. PCI for bifurcated CAD is associated with higher restenosis rates and procedural complications, so the optimal management strategy remains the focus of intense research and debate. A specially designed double-lumen microcatheter can be used for difficult bifurcation lesion recanalization, and to save time and devices. This report presents 2 cases of CTOs with bifurcation lesions that were successfully treated with adjunctive double-lumen microcatheters to achieve vessel preservation. This technique is simple and reliable, and warrants more clinical practice for validation.
J INVASIVE CARDIOL 2010;22:E99–E103
bifurcation, chronic total occlusion, microcatheter
Successful recanalization of the chronic total occlusion (CTO) of coronary arteries is possible thanks to improvements in new devices, equipment and expertise, including the use of the retrograde approach.1,2
It has been demonstrated to relieve ischemic symptoms, improve left ventricular (LV) function and secure long-term survival.3,4
Percutaneous coronary intervention (PCI) for CTO with bifurcation lesions is a special overlapping subset of CTO and bifurcated coronary artery disease (CAD) management. Sometimes, only the main branches are treated because of the difficulties with large side-branch angles, long procedural times, small side branch diameters, the lack of wire protection for the side branches or the failure of recrossing the side branches after stenting.
PCI for bifurcated CAD is associated with higher restenosis rates and more significant procedural complications compared to those of nonbifurcated lesions.5–7
The optimal management strategy is the focus of intense research and debate.6
The Crusade catheter (Kaneka Corp., Tokyo, Japan) is a double-lumen microcatheter (Figure 5) designed for adjunctive management of bifurcation lesions, but its clinical use for CTOs with bifurcation lesions has not yet been discussed. This report concerns 2 cases of CTOs with bifurcation lesions that were successfully treated with the adjunctive Crusade microcatheter to maintain patent vessels.
Case 1. A 65-year-old female presented with stable exertional angina. Thallium scintigraphy revealed reversible ischemia in the anterior wall of the left ventricle. Diagnostic angiography showed distal left main (LM) disease (Figure 1A) and CTO of the left anterior descending artery (LAD) (Figures 1A and 1B), with epicardial collateral circulation from the right coronary artery (RCA) (Figure 1C). Biradial PCI to the LAD was performed with two 6 Fr IL 3.5 guide catheters (Terumo Corp., Tokyo, Japan) (the left radial artery for an antegrade approach, and the right radial artery for contralateral contrast injection and a retrograde approach, if necessary). A Fielder FC wire (Asahi Intecc Ltd., Tokyo, Japan), a Miracle 3 wire (Asahi Intecc) and a 1.5 Fr Quick-Cross mi- crocatheter (Spectranectics Corp., Colorado Springs, Colorado) were used for negotiating the CTO of the LAD. Unfortunately, these wires could not cross the culprit LAD and easily prolapsed to the diagonal branch, even when using the Quick-Cross microcatheter (Figure 1D).
We introduced a Crusade microcatheter to the bifurcation of the LAD and diagonal branch. The Miracle 3 wire negotiated the LAD successfully and as demonstrated by angiography of the contralateral injection (Figure 1E). After predilatation, a Cypher 3.0 x 33 mm drug-eluting stent (Cordis Corp., Miami Lakes, Florida) was deployed from the distal LM to the LAD (Figure 1F). Because the ostium of the left circumflex artery (LCx) was pinched, kissing-balloon angioplasty of the LM-to-LAD and LM- to-LCx was undertaken using 2 Maverick 3.0 x 20 and 2.5 x 20 mm balloons (Boston Scientific Corp., Natick, Massachusetts) (Figure 2A). The final angiogram demonstrates the optimal results (Figures 2B and 2C).
Case 2. A 60-year-old male with hypertension underwent diagnostic coronary angiography because of exertional angina and findings of myocardial ischemia on thallium scintigraphy. The angiography revealed moderate LM disease (around 38–44% stenosis by quantification coronary analysis; Siemens Axiom Artis Zee) and CTO of the mid-LCx (Figure 3A) with collateral circulation from the RCA (Figures 3B and 3C). Left transradial PCI for CTO LCx was per- formed, guided with a right transradial contralateral RCA contrast injection. A 6 Fr BL3.5 (Terumo) guide catheter, a 1.8 Fr Finecross (Terumo) microcatheter, and Miracle 3 and 6 (Asahi Intecc) guidewires were chosen. The first obtuse marginal (OM1) was successfully negotiated with the Miracle 6 wire. A 5 Fr ST01 catheter (Terumo) (Figure 3D) was introduced into the 6 Fr BL 3.5 catheter (5-in-6 technique) for stronger support, while a Sprinter Legend (Medtronic, Inc., Minneapolis, Minnesota) 1.25 x 6 mm balloon and an Ottimo (Kaneka) 1.5 x 10 mm balloon crossed the tight CTO for predilatation (Figure 3D). The angiogram shows that the tract of the mid-LCx to OM1 was negotiated suc- cessfully, but the distal LCx was still occluded (Figure 3E).
Because the distal LCx could not be crossed with the Miracle 3 and 6 wires alone, a Crusade microcatheter was introduced, which allowed the Miracle 6 wire to cross the distal LCx (Figures 3F and 4A). The distal LCx predilatation was performed with an Ottimo 1.5 x 10 mm balloon (Kaneka) and a Hiryu 3.0 x 15 mm balloon (Terumo). A Xience V (Abbott Vascular, Santa Clara, California) 3.0 x 28 mm DES was deployed to the mid LCx (Figure 4B), but the OM1 was jailed and demonstrated the no-reflow phenomenon (Figure 4C).
Successful recrossing of the OM1 was achieved with a Whisper (Abbott) hydrophilic wire, and Crusade microcatheter support. The stent strut was predilated with a Sprinter Legend 1.25 x 6 mm balloon, and kissing-balloon angioplasty was completed with two 3.0 x 15 and 2.5 x 15 mm Hiryu balloons (Terumo) (Figure
4D). The final angiogram demonstrates optimal results (Figures 4E and 4F).
In the first case, the culprit lesion was located at the junction of the LAD and diagonal branch, although the angiogram revealed critical stenosis of the LAD ostium. The wire negotiation was difficult because of the hard plaques and acute entry angle. Furthermore, the collateral circulation was epicardial, thus it may have been too difficult for the retrograde approach. Use of the Crusade microcatheter stabilized and supported the guide wires, resulting in successful LAD negotiation.
In the second case, the CTO segment was long and ended at the carina of the bifurcation. The LM disease could have increased the risk of PCI complications because device-induced (catheter or wire) plaque rupture, or coronary dissection could occur, or even acute occlusion and/or thrombosis. With adequate catheter back-up support (BL 3.5, ST01, and Finecross), wire negotiation and small balloon delivery across the CTO was able to be done smoothly. The tract of the proximal LCx to the OM1 was crossed successfully, but the other tract to the distal LCx is often difficult to negotiate, even with a stiff-tip wire. Possible reasons include the bifurcation angle, previous hard plaque obstruction and plaque shift from the OM1 after balloon angioplasty. These situations can easily cause wire deviation and result in coronary dissection, false-lumen creation and even perforation and cardiac tamponade.
In the two cases, a back-up device to support and stabilize wire tracking and negotiation was required. The Crusade double-lumen microcatheter is an ideal support device for recanalization of CTOs with bifurcation lesions. The wire in the monorail lumen can fix and stabilize the microcatheter, while the wire in the over-the-wire lumen reaches out of the side hole (about 8.5 mm beyond the catheter tip) and can be directed towards the culprit lesion. Moreover, the choice of guidewire is also important. Based on these experiences, hydrophilic wires with at least intermediate strength (e.g., Abbott Pilot 50, Asahi Miracle 3) are recommended. The combined use of the Crusade micro-catheter and intermediate hydrophilic wires is effective and can increase the success rate of the antegrade approach for CTOs and save procedural time and devices, including the use of guide catheters and wires.
In daily practice, when formulating a management strategy, the operator should address the individual morphologic components of the bifurcation.8
Because of a wide variety of anatomic considerations, it is not sufficient to simplify the lesion anatomically based on disease distribution of the main and side branches.8
Other important factors must be considered, including side-branch angulations, the extent of lesion calcification and vessel diameter.8
Although the reported experience is limited, we hope that adjunctive use of the Crusade microcatheter will help clinicians treat CTOs with bifurcation lesions more efficiently.
This report is about two interesting cases that highlight successful recanalization of CTOs with bifurcation lesions using adjunctive Crusade double-lumen microcatheter support. This technique is simple and reliable and warrants further clinical practice for validation.
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From the Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan, R.O.C.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted September 18, 2009, provisional acceptance given October 12, 2009, final version accepted December 4, 2009.
Address for correspondence: Cheng-An Chiu, MD, Division of Cardiology,
Department of Internal Medicine, E-Da Hospital, I-Shou University, No.1, Yi-Da Rd, Jiau-Shu Village, Yan-Chao Township, Kaohsiung 82445, Taiwan, R.O.C. E-mail: firstname.lastname@example.org