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Subintimal TRAnscatheter Withdrawal (STRAW) of Hematomas Compressing the Distal True Lumen: A Novel Technique to Facilitate Distal Reentry During Recanalization of Chronic Total Occlusion (CTO)

Elliot J. Smith, MD, MRCP1;  Carlo Di Mario, MD, PhD2;  James C. Spratt, MD, FRCP3;  
Colm G. Hanratty, MD4;  Ranil de Silva, MD, PhD2,5;  Alistair C. Lindsay, MD, MBA, PhD2;  J. Aaron Grantham, MD6

Elliot J. Smith, MD, MRCP1;  Carlo Di Mario, MD, PhD2;  James C. Spratt, MD, FRCP3;  
Colm G. Hanratty, MD4;  Ranil de Silva, MD, PhD2,5;  Alistair C. Lindsay, MD, MBA, PhD2;  J. Aaron Grantham, MD6

Abstract: The development of a large hematoma impairing visualization of the distal true lumen is a recognized complication of antegrade recanalization of chronic total occlusions, often forcing the operator to abort the procedure or switch to a retrograde approach. We describe a novel technique utilizing an over-the-wire balloon inflated in the proximal occluded vessel to block inflow and allow aspiration of the blood from the subintimal space. This decompressed the true lumen, restored distal visualization, and allowed successful reentry using a dedicated technology. Utilization of this novel technique may rescue antegrade recanalization attempts complicated by large subintimal hematomas.

Key words: complication, hematoma, antegrade PCI

The development of a large hematoma impairing visualization of the distal true lumen is a recognized complication of antegrade recanalization of chronic total occlusions (CTOs), often forcing the operator to abort the procedure or switch to a retrograde approach, when feasible.1 With the exception of the subintimal tracking and reentry (STAR) technique,2 which relies on blind forceful advancement of a knuckled wire into the distal branches to create a communication between true and false lumens, the controlled methods of distal reentry (parallel wire, see-saw, intravascular ultrasound [IVUS]-guided reentry, and Stingray balloon and wire system [Boston Scientific Corporation]) require visualization and filling of the distal vessel.3-5 We describe a novel technique utilizing an over-the-wire (OTW) balloon inflated in the proximal occluded vessel to block inflow and allow continuous aspiration of the blood contained in the subintimal space. This case demonstrates this technique’s ability to decompress the true lumen and restore distal visualization, allowing successful controlled reentry with the Stingray balloon and wire system.

Case Presentation

A 65-year-old patient with a history of previous coronary bypass surgery and limiting angina was referred for a repeat (third) attempt to recanalize a chronically occluded right coronary artery (RCA). The occlusion was 35 mm long; the reentry zone was favorable, with distal visualization from ipsilateral bridging and contralateral septal collaterals (Figure 1A). Unfortunately, the collateral circulation did not allow for a retrograde approach because the left anterior descending (LAD) coronary artery was only accessible via the retrograde limb of a left internal mammary artery (LIMA) graft to a large diagonal branch (Figure 1B).


An 8 Fr Amplatz right 1 guiding catheter (Medtronic) and a diagnostic 5 Fr LIMA catheter were engaged in the RCA and LIMA ostium, respectively. Despite a 2.0 x 12 mm monorail anchor balloon in the conus branch for support, a CrossBoss catheter (Boston Scientific Corporation) was unable to penetrate the proximal cap of the occlusion. After a small entry was created with a Confianza 12 wire the CrossBoss catheter kept advancing straight, probably following ventricular branches. Therefore, a Pilot 200 knuckled guidewire (Abbott Vascular) was advanced with support from a Corsair microcatheter (Asahi-Intecc) to redirect progression along the subintimal space of the proximal and mid-RCA, stopping above the reentry site and avoiding injections from the antegrade guiding catheter. However, at this point, retrograde injections demonstrated complete loss of visualization of the distal RCA up to the crux (Figure 1C). A second wire was advanced into the subintimal space and a 2.5 x 15 mm Apex OTW balloon (Boston Scientific Corporation) was positioned in the proximal vessel at the site of origin of the dissection plane. Following inflation, a 10 mL syringe was attached to the proximal lumen port on negative pressure, yielding 2-3 mL of blood. Repeat contralateral injections demonstrated decompression of the mid-RCA and restored visualization of the reentry zone (Figure 1D). Confirmation of the importance of the proximal occlusion and aspiration to achieve decompression was obtained when the Apex OTW balloon (3.4 Fr proximal, 2.4 Fr distal shaft) had to be removed in order to advance the Stingray catheter shaft (3.7 Fr proximal, 2.9 Fr distal shaft). With the Stingray balloon advanced subintimally in a straight segment of the mid-RCA beyond the original reentry site, retrograde injection once again demonstrated complete loss of distal visualization, not restored by the inflation of a Monorail 2.5 mm balloon in the same position as the preceding OTW balloon (Figure 2A). Fortunately, a new OTW balloon from a different manufacturer (2.5 x 20 mm Ryujin; Terumo Corporation) had a sufficiently small shaft diameter (2.7 Fr distal, 3.2 Fr proximal) to be advanced in the 8 Fr catheter with the Stingray left in place. After inflation and aspiration, distal visualization was restored (Figure 2B). Unlike the first aspiration, which only collected 2-3 mL of blood, blood was continuously aspirated during the procedure (20 mL in total), probably due to seepage around the balloon caused by the parallel insertion of the Stingray. True lumen reentry was performed using the Stingray wire in the distal RCA before the crux. After confirmation of the position of the distal wire in the true lumen with contralateral injections (Figure 2C), the Stingray wire was exchanged for a Fielder FC wire (Asahi-Intecc) using a “stick-and-swap” technique, the OTW and Stingray balloons were removed, and the lesion was predilated and successfully treated with two 38-mm long drug-eluting stents (Figure 2D).


Successful CTO recanalization improves prognosis,6,7 and progress in revascularization techniques has greatly increased success and widened indications in the past 10 years.8 We describe the first use of Sub-intimal TRAnscather Withdrawal (STRAW) of a compressive hematoma, resulting in decompression of the distal true lumen to facilitate controlled reentry during CTO percutaneous coronary intervention (Figure 3).  

Certain anatomical subsets may indicate a greater tendency for loss of distal visualization; these include a reliance on ipsilateral collaterals (as in this case) and a relatively low plaque volume in the distal coronary bed. The presented case highlights the need to avoid hematoma propagation in the subintimal space when using dissection and reentry techniques; avoidance maneuvers include meticulous wire control using a small diameter (1-2 mm) bend on the guidewire, use of a trapping balloon in the guide catheter for microcatheter exchanges to prevent inadvertent wire movement and distal extension of the subintimal dissection, and the avoidance of antegrade injections. New technologies such as the CrossBoss catheter, which has an atraumatic 3 Fr diameter distal tip that allows blunt dissection through the subintimal space, certainly limit hematoma formation,5 but cannot always reach the distal reentry point without the synergistic use of wires to perforate the proximal cap or redirect the CrossBoss along curved segments. However, despite the best precautions, compression of the distal true lumen is a common failure mode of all techniques of antegrade recanalization. Options are limited in this setting. Attempts at reentering a virtually fully collapsed lumen are often unsuccessful, even with the use of IVUS guidance or a Stingray balloon. An alternative is to move the planned reentry point distally by using the STAR technique2 or by advancing the Stingray balloon (the so-called “bob-sledding” technique); however, both of these techniques risk an unpredictable final result with the creation of very long dissections up to the terminal branches. Retrograde crossing was not possible in this particular case.

In the presented case, the hematoma, resulting from the passage of a knuckled guidewire, had already propagated all the way to the bifurcation of the posterior descending artery and right posterolateral ventricular branches; without the application of the STRAW technique, the operators would have considered abandoning the procedure to allow healing and hematoma resolution, with repeat intervention and case completion at a later date. The use of a proximal monorail balloon did not restore distal vessel visualization, and demonstrated that prevention of antegrade blood flow into the subintimal space alone without aspiration was insufficient to achieve true lumen decompression; an inflated balloon was necessary to block inflow while aspirating distally. Use of large guiding catheters (7 Fr in combination with microcatheters, 8 Fr in combination with IVUS catheters, 8 Fr and low-profile OTW balloons in combination with the Stingray catheter) is therefore indispensable for the successful application of this technique.  Although not tested here, if a low-profile OTW balloon is not available, inflation of a proximal low-profile monorail balloon, followed by aspiration of an inflated Stingray balloon, may allow decompression of the true lumen. However, without active aspiration during reentry wiring, reexpansion of the subintimal hematoma might occur.


The STRAW technique for distal true lumen decompression was the key to successful reentry in a complex long CTO with no retrograde options. Utilization of this novel technique may rescue antegrade attempts of recanalization complicated by large subintimal hematomas.

Acknowledgment. This case was part of an interactive CTO Live Course conducted in the NHLI Cardiovascular Biomedical Research Unit of the Royal Brompton Hospital. We gratefully acknowledge sponsorship of this course by the NHLI Cardiovascular Biomedical Research Unit of the Royal Brompton Hospital & Harefield Foundation Trust, Bridgepoint Medical Systems, and Abbott Vascular.


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From the 1NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London, United Kingdom; 2Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom; 3Forth Valley Royal Hospital, Larbert, United Kingdom; 4Belfast Health and Social Care Trust, Belfast, United Kingdom; 5National Heart and Lung Institute, London, United Kingdom; 6Saint Luke’s Mid America Heart Institute, Kansas City, Missouri.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Grantham reports honoraria and grants from Abbott Vascular, Terumo, Vascular Solutions, Bridgepoint Medical Systems, and Banyan Medical Systems all paid directly to Saint Luke’s Hospital Foundation. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript submitted June 30, 2014, provisional acceptance given July 23, 2014, final version accepted July 29, 2014.

Address for correspondence: Dr J. Aaron Grantham, Saint Luke’s Mid America Heart Institute, MAIH 5603, 4401 Wornall Road, Kansas City, MO 64111. Email: