ABSTRACT: Antegrade wiring of chronic total occlusions (CTO) may fail due to subintimal wire entry and inability to reenter the true lumen. We report the use of the Venture® wire control catheter to reenter the true lumen after subintimal entry in a long right coronary artery CTO.
J INVASIVE CARDIOL 2010;22:445–448
Key words: percutaneous coronary intervention, chronic total occlusion, endovascular technique, Venture catheter
Failure of chronic total occlusion (CTO) angioplasty is most often due to failure to cross the lesion. Attempts for antegrade CTO crossing may be complicated by subintimal wire entry and failure to reenter the true vessel lumen distal to the CTO. Several techniques have been proposed to solve this problem such as the “parallel” and “see-saw” wire techniques, guide anchoring, intravascular ultrasound (IVUS) guidance, the subintimal tracking and reentry (STAR) technique, use of the Stingray® guidewire (Bridgepoint Medical, Minneapolis, Minnesota), or using a retrograde approach. We report the successful use of the Venture® wire control catheter (St. Jude Medical, Minneapolis, Minnesota) for reentering the true lumen in a challenging CTO case. Case Example. A 61-year-old female with prior three-vessel coronary artery bypass surgery, hypertension and hyperlipidemia presented with Canadian Cardiovascular Society Class III angina, refractory to medical therapy. Diagnostic coronary angiography revealed a 50% mid left anterior descending (LAD) artery lesion, a 70% proximal left circumflex lesion and a proximally chronically occluded right coronary artery (RCA) (Figures 1A–1C). The right posterior descending artery (PDA) was supplied by a collateral from the distal circumflex artery (Figures 1A and 1B). A left internal mammary artery graft to the LAD and a saphenous vein graft to the obtuse marginal branch were both patent, whereas a saphenous vein graft to the RCA was occluded. Percutaneous coronary intervention (PCI) of the RCA CTO was attempted. Dual arterial access was obtained. The left main coronary artery was engaged with a 7 French (Fr) XB 3.5 (Cordis Corp., Bridgewater, New Jersey) guiding catheter and the RCA was engaged with a 7 Fr AL 0.75 guiding catheter. Anticoagulation was achieved with intravenous unfractionated heparin. Antegrade attempts to cross the RCA CTO with several stiff guidewires (Miracle 6, Confianza Pro 12; Abbott Vascular, Santa Clara, California) through an over-the-wire balloon failed due to subintimal wire entry (Figure 1D). We considered attempting a retrograde intervention, but the circumflex to RCA epicardial collateral vessel was extremely tortuous (Figures 1A and 1B). While attempting the antegrade approach using the Confianza wire, we inadvertently entered into the subintimal space and exchanged for a Whisper extra-support wire (Abbott Vascular) with a pre-shaped loop (Figure 2B). We advanced the guidewire loop through the subintimal space beyond the distal CTO at the point of reconstitution of the distal RCA visualized via contralateral left coronary injection (Figures 2B and 2C). We were unable to reenter the true lumen despite using multiple guidewires (Miracle 12, Confianza Pro 12, and Pilot 200 – Abbott Vascular), so the Venture catheter was advanced into the distal vessel over the guidewire and a 90° bend was formed by rotating the control knob. Unfortunately, the wire kept going into a right ventricular marginal artery branch (Figure 2D). The loop of wire was withdrawn and then advanced further distally to the distal RCA, where we were successful at penetrating the true vessel lumen with a Pilot wire. This was achieved by exchanging the extra-support Whisper wire for a Pilot guidewire and successful distal RCA reentry by directing the Venture catheter toward the distal true vessel lumen (Figure 3A) visualized by contralateral left coronary injections. Distal true lumen access was confirmed by successful advancement of the guidewire into the left circumflex to PDA epicardial collateral vessel (Figure 3B) and by IVUS after initial predilatation of the subintimal space with a 1.5 x 20 mm Sprinter balloon. We then successfully implanted 5 overlapping Xience drug-eluting stents (Abbott Vascular, Redwood City, California) from the distal RCA to the proximal RCA (Figure 3C). Final angiography and intravascular ultrasound revealed well-expanded stents with thrombolysis in myocardial infarction (TIMI) 3 flow (Figure 3D).
DiscussionSuccessful recanalization and PCI of coronary arteries with CTOs remains a formidable challenges in interventional cardiology. Our case demonstrates for the first time use of the Venture wire control catheter for true lumen reentry after subintimal wire passage during CTO-crossing attempts. Several techniques have been proposed after antegrade subintimal wire entry. First, The parallel-wire method makes use of two guidewires simultaneously to approach the distal true lumen of CTO lesions. It is hypothesized that the first guidewire serves as a landmark for the operator while the second guidewire is advanced to negotiate the true lumen. The “see-saw” wiring method is when a parallel-wire method is performed using two full sets of over-the-wire microcatheters with a guidewire inside each. It was named the see-saw wiring method because if the second wire failed to negotiate the distal true lumen, the first wire would change its role to penetrate the true lumen while utilizing the second wire as a landmark, and their roles could be alternated in a back-and-forth sequence (see-saw) at any moment without having to exchange the microcatheter or the guidewire, as is required with the conventional parallel-wire method.1 Second, the Stingray™ CTO Re-Entry System (BridgePoint Medical, Plymouth, Minnesota) can be used for true lumen reentry. It has two components: the Stingray CTO Orienting Balloon Catheter and the Stingray CTO Re-Entry Guidewire. The flat shape of the Stingray CTO Orienting Balloon Catheter is intended to orient one exit port automatically toward the vessel true lumen upon low-pressure inflation (4 atmospheres).2 The Stingray balloon and Stingray wire are currently studied in the FAST CTO in trial and are not widely commercially available yet. Third, the subintimal tracking and reentry (STAR) technique described by Colombo et al3 can be used. STAR involves creation of a cleavage subintimal plane by advancing a 0.014 hydrophilic wire with a J-loop configuration to allow a blunt dissection between the anatomical planes of the vessel. There is no wire manipulation to reenter the true lumen, and usually the wire will spontaneously reenter the very distal small vessels, usually at a point where the vessel is smaller than the J-loop but it is an uncontrolled dissection and reentry by chance. Some limitations of the STAR technique include sometimes the inability to create a dissection plane in the CTO and when it is done, the subintimal dissection is created with little or no angiographic guidance, and the operator frequently relies on the “usual” anatomical distribution of the occluded vessel and on the resistance felt during attempts to advance the wire. To avoid this, Carlino et al have proposed the contrast guided STAR technique,4 which uses a catheter injection method, but there is a potential for an uncontrollable hydraulic dissection, which can sometimes occur and limit the procedural success. Fourth, retrograde CTO PCI techniques can be used. The controlled antegrade and retrograde subintimal tracking (CART) technique involves the simultaneous use of the antegrade and retrograde approaches. CART aims to create a subintimal dissection with limited extension only at the site of the CTO. A wire is advanced from an antegrade proximal true lumen location into the CTO, and then enters into the subintimal space at the CTO site. Another wire is advanced through a collateral vessel to the distal end of the CTO, then is used to penetrate in a retrograde fashion from the distal true lumen into the CTO. If the retrograde wire enters the subintimal space at the CTO site, then a balloon (preferably the same size as the vessel) is placed on the retrograde wire and inflated in the subintimal space as well as on the course from this subintimal space to the distal end of the CTO, followed by advancement of the antegrade wire into this newly created space and into the distal true lumen. This technique allows limited subintimal tracking only in a portion of the CTO lesion and avoids the difficulty of reentering the distal true lumen.5 In reverse CART technique, the balloon is advanced over the antegrade wire and inflated in the subintimal space to facilitate reentry of the retrograde wire into the true lumen proximally. One of the advantages of using the reverse CART is the use of IVUS advanced over the antegrade wire, which can help in appropriate sizing the antegrade balloon to the vessel size and to also visualize the retrograde wire coming back into the true lumen.6,7 Collateral vessels for retrograde access can be distinguished as epicardial or septal. Compared to septal collaterals, epicardial collaterals are tortuous and have a long course, which can make wire handling and advancement of a balloon or support catheters extremely challenging and prone to perforation. In addition, unlike the septal collaterals, perforation of epicardial collaterals is associated with a significantly greater risk of serious complications such as pericardial tamponade or extensive myocardial ischemia, especially in situations where epicardial collaterals constitute a major feeding route for a distal target vessel, as illustrated by this case. While we do not recommend not using an epicardial collateral for retrograde cases, operators must realize that although both septal and epicardial collaterals can be used, both have inherently different risks and procedural techniques associated with them (i.e., always dilate septal and never dilate epicardial arteries, etc.) and also requires a different knowledge base to handle. Some experienced operators equally use epicardial and septal collaterals for retrograde CTO PCI. Our case demonstrates the successful use of the Venture catheter. The Venture is a 6 Fr-compatible, single-use, torqueable support catheter with a mechanically activated deflectable 8 mm radiopaque atraumatic tip. The tip may be deflected to any degree between 0 and 90, resulting in enhanced directional control and support. This may prove beneficial not only in rigid and tortuous vessels, but in chronic occlusions and high-grade stenoses, angulated takeoffs, ostia of bifurcations and stent-jailed side branches. As described in our case, the torque handle of the Venture catheter can be rotated to direct the guidewire distally toward the true lumen beyond the CTO (Figure 3). The technique we propose has the advantage of subintimal dissection being limited rather than performed over the entire vessel length, as in the STAR technique, therefore limiting side-branch occlusion. The Venture catheter is also widely available in contrast to the Stingray balloon and wire, which are currently under limited release. When performing antegrade subintimal dissections, antegrade contrast injections should be strictly avoided to minimize expansion and staining of the subintimal space. Use of the Venture catheter should be done with care, as advancement into the subintimal space could enlarge the subintimal space and actually hinder true lumen reentry. Moreover, there is a risk of vessel perforation. In summary, use of the Venture catheter may facilitate wire reentry into the true lumen after subintimal wire crossing.
1. Mitsudo K, Yamashita T, Asakura Y, et al. Recanalization strategy for chronic total occlusions with tapered and stiff-tip guidewire. The results of CTO new techniQUE for STandard procedure (CONQUEST) trial. J Invasive Cardiol 2008;20:571–577. 2. Brilakis ES, Banerjee S. Use of the Stingray® Guidewire and the Venture® Catheter for crossing flush coronary chronic total occlusions due to in-stent restenosis. Catheter Cardiovasc Interv 2010, in press. 3. Colombo A, Mikhail GW, Michev I, et al. Treating chronic total occlusions using subintimal tracking and reentry: The STAR technique. Catheter Cardiovasc Interv 2005;64:407–411; discussion 12. 4. Carlino M, Godino C, Latib A, et al. Subintimal tracking and re-entry technique with contrast guidance: A safer approach. Catheter Cardiovasc Interv 2008;72:790–796. 5. Surmely JF, Tsuchikane E, Katoh O, et al. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: The CART technique. J Invasive Cardiol 2006;18:334–338. 6. Rathore S, Katoh O, Tsuchikane E, et al. A novel modification of the retrograde approach for the recanalization of chronic total occlusion of the coronary arteries intravascular ultrasound-guided reverse controlled antegrade and retrograde tracking. JACC Cardiovasc Interv 2010;3:155–164. 7. Tsuchikane E, Katoh O, Kimura M, et al. The first clinical experience with a novel catheter for collateral channel tracking in retrograde approach for chronic coronary total occlusions. JACC Cardiovasc Interv 2010;3:165–171.
_______________________________________________________ Neeraj Badhey, MD*, William L. Lombardi, MD†, Craig A. Thompson, MD, MMSc£, Emmanouil S. Brilakis, MD, PhD, FSCAI*, Subhash Banerjee, MD, FSCAI*
From *VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, Texas; †St. Joseph Hospital, Bellingham, Washington; £Yale University School of Medicine, New Haven, Connecticut. Disclosures: Dr. Brilakis has received speaker honoraria from St. Jude Medical, consulting fees from Medicure, and research funding from Abbott Vascular; Dr. Banerjee has received speaker honoraria from St. Jude Medical, Cordis, and Medtronic and research support from Boston Scientific. Dr. Lombardi is on the medical advisory board of Abbott Vascular, and is a consultant for Medtronic and Bridgepoint Medical. Dr. Thompson is on the medical advisory board of Abbott Vascular and Infraredx, and is a consultant for Medtronic and BridgePoint Medical. Manuscript submitted March 9, 2010 and accepted April 9, 2010. Address for correspondence: Subhash Banerjee, MD, FSCAI, Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216. E-mail: email@example.com