ABSTRACT: Percutaneous coronary intervention (PCI) for the treatment of chronic total occlusion (CTO) is one of the most technically challenging areas of interventional cardiology. When CTO is combined with angulation and tortuosity of the coronary artery, the technical complexity of PCI for CTO is magnified. In this report, we describe a case of successful revascularization of a CTO lesion in the complex circumflex anatomy using a novel microcatheter (the Corsair catheter) along with an antegrade approach to facilitate guidewire passage through a proximal steep angulation and to cross the circumflex CTO lesion that was unresponsive with conventional microcatheters.
J INVASIVE CARDIOL 2012;24(2):E35-E38
Key words: microcatheter, chronic total occlusion, percutaneous coronary intervention
Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of coronary arteries is one of the most technically challenging areas for the interventional cardiologist with lower procedural success rates and higher complication rates compared with those for the non-occluded coronary arteries or acutely-occluded arteries. In addition, clinical and angiographic restenosis or re-occlusion occurs with greater frequency after PCI of CTOs compared with non-occluded lesion.1 However, it has been reported that successful revascularization of a CTO leads to a significantly improved survival rate and a reduction in major cardiac adverse event in patients in the long term.2-4
Drug-eluting stents (DES) have been demonstrated to markedly reduce in-stent restenosis for on-label and off-label lesions5,6 including CTO lesions.7,8 Long-term patency and freedom from restenosis after successful recanalization of CTOs with DES greatly reduce the rate of mortality and cardiac events. Furthermore, several procedural techniques such as retrograde approach and various devices for CTO lesions have been recently developed and subsequently success rates of CTO recanalization have increased.9-14
The complexity of PCI for CTO is magnified when CTO lesion is combined with angulation and tortuosity of the coronary artery. Proximal steep angulation quite likely contributes to the reduced success rate of interventions on chronically occluded circumflex arteries observed in some series.15,16
In this report, we describe a case of successful complex circumflex PCI using a novel microcatheter (the Corsair catheter) antegradelly to facilitate guide wire advancement through a proximal angulated circumflex CTO lesion that was unresponsive with conventional microcatheters.
Case Report. A 40-year-old male patient with multiple coronary risk factors of hypertension, hyperlipidemia, diabetes mellitus and hyperuricemia was admitted to our hospital because of angina pectoris. He had established end-stage renal disease and had already been on hemodialysis before admission. Coronary angiography showed a CTO of the proximal left circumflex (LCx) artery combined with steep angulation (Figures 1a and b). PCI was performed using an antegrade approach. A 6 Fr BL 4.0 Heartrail guiding catheter (Terumo) or a 7 Fr BLH Brite tip guiding catheter (Cordis) was used via the right femoral artery. We tried to proceed the Finecross microcatheter, (Terumo) to the completely occluded LCx artery using a Rinato guidewire (Asahi Intecc), but multiple attempts to deliver the micro-catheter to the LCx occlusion were unsuccessful due to the prolapse of microcatheter into the patent left anterior descending (LAD) artery (Figures 1c and d). The extremely steep angle of LCx artery in its take-off from the very large left main trunk seemed to the cause of the difficulty to advance the microcatheter. To take more co-axial direction to the LCx artery, the guiding catheter was changed to a 6 Fr Amplatz 3.0 Heartrail guiding catheter. Then, an X-treme guidewire (Asahi Intecc) was used to select the atrial branch for a Finecross micro-catheter delivery (Figure 1e) and the Finecross micro-catheter could successfully cross the steep angle of LCx artery (Figure 1f). Subsequently, an X-treme guidewire and the Finecross micro-catheter were further advanced toward the proximal part of the CTO lesion. A Wizard 3 (Japan Lifeline), a Miracle 6, and a Conquest Pro guidewire (Asahi Intecc) were used to cross this CTO lesion but were unsuccessful because of insufficient backup guidewire support (Figures 2a and b). Therefore, we changed the micro-catheter to a Corsair micro-catheter. A Corsair micro-catheter was easily advanced toward the just proximal part of the CTO lesion using a similar method. Finally, the Conquest Pro guidewire (Asahi Intecc) was able to cross this CTO lesion (Figure 2c). Although a Corsair micro-catheter was not able to cross this CTO lesion, a 1.25-mm x 10-mm Tazuna balloon (Terumo) was able to cross and successfully dilated the CTO lesion. A 2.5-mm x 15-mm Signet Pro balloon (St. Jude Medical) was then used to open this CTO lesion further. Stent implantation was successfully performed using a 3.5-mm x 23-mm Xience V stent (Abbott). Final coronary angiogram showed a satisfactory result without any complications (Figures 2d and 2e).
Discussion. Microcatheter technique provides support to advance the guidewire and is useful in the PCI of complex anatomy. However, this technique is occasionally insufficient for the treatment of CTO combined with angulation, tortuousity and severe calcification of the coronary artery. In the treatment of the lesion in the LCx artery with a steep angle in its take-off from left main trunk, a prolapse of the distal wire and the support catheter such as the over-the-wire balloon or microcatheter frequently occurs and the procedure fails. If a sufficient length of wire could not be placed distally from the proximal angulation, an advancement of the microcatheter would be impossible and could not give enough support to cross a CTO lesion with wire, and vice versa. Recently, it has been reported that the utility of the deflectable tip Venture Catheter17 or Twin-Pass catheter,18 or double catheter technique using a 5 Fr VERT catheter19 facilitated guidewire crossing during PCI for complex proximal circumflex lesions. However, these devices are uncommonly available for daily practice.
The Corsair microcatheter (Asahi Intecc) was originally developed as a collateral channel dilator to facilitate retrograde approaches for PCI of CTO.20 This is an over-the-wire hybrid catheter that has features of a microcatheter and a support catheter. The shaft consists of 8 thin wires wound with 2 larger wires.20 On the other hand, the shaft of the Tornus microcatheter (Asahi Intecc), which was useful for calcified lesion, consists of 8 larger wires wound.21,22 The spiral structure of Corsair microcatheter allows the bidirectional rotation gives crossing capability in small tortuous collateral channels (Figure 3). The braided portion of the catheter is covered with polyamide elastomer, and the inner lumen of the shaft is lined with a fluoropolymer layer that enables tip injections and facilitates the guidewire movement. The table demonstrates the details of the 4 microcatheters: 2.1 Fr Tornus, 2.6 Fr Tornus, Corsair and Finecross microcatheters. The characteristic features of the Corsair microcatheter are as follows: the smallest outer and inner diameter for the distal tip, the smallest inner diameter and the larger outer diameter for the distal part, the smallest inner diameter and the larger outer diameter for the proximal part, which gives better crossability of the distal tip and better backup guidewire support compared with conventional micro-catheter.
It has been reported that PCI for CTO lesions with the Corsair micro-catheter in the retrograde approach had a high success rate and this was attributed to the enhanced crossability in the collateral channel and better backup guidewire support.20 Although this catheter was developed for retrograde approach PCI of CTO,20 these characteristics are also useful for antegrade approach PCI of the CTO lesion whenever angulation and tortuousity of the coronary artery is encountered as in the case we describe here that was initially unresponsive with a conventional micro-catheter (Figure 3). Therefore, the Corsair micro-catheter could be the first choice for the CTO-PCI with severe or complex lesion morphology, not only after a failed attempt of the retrograde approach, but also when making an initial attempt using an antegrade approach.
- Stone GW, Kandzari DE, Mehran R, et al. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I. Circulation. 2005;112:2364-2372.
- Aziz S, Stables RH, Grayson AD, et al. Percutaneous coronary intervention for chronic total occlusions: improved survival for patients with successful revascularization compared to a failed procedure. Catheter Cardiovasc Interv. 2007;70:15-20.
- Noguchi T, Miyazaki S, Morii I, et al. Percutaneous transluminal coronary angioplasty of chronic total occlusions. Determinants of primary success and long-term clinical outcome. Catheter Cardiovasc Interv. 2000;49:258-264.
- Ivanhoe RJ, Weintraub WS, Douglas JS Jr, et al. Percutaneous transluminal coronary angioplasty of chronic total occlusions. Primary success, restenosis, and long-term clinical follow-up. Circulation. 1992;85:106-1
- Beohar N, Davidson CJ, Kip KE, et al. Outcomes and complications associated with off-label and untested use of drug-eluting stents. JAMA. 2007;297:1992-2000..
- Marroquin OC, Selzer F, Mulukutla SR, et al. A comparison of bare-metal and drug-eluting stents for off-label indications. N Engl J Med. 2008;358:342-352.
- Nakamura S, Muthusamy TS, Bae JH, et al. Impact of sirolimus-eluting stent on the outcome of patients with chronic total occlusions. Am J Cardiol. 2005;95:161-166.
- García-García HM, Daemen J, Kukreja N, et al. Three-year clinical outcomes after coronary stenting of chronic total occlusion using sirolimus-eluting stents: insights from the rapamycin-eluting stent evaluated at Rotterdam cardiology hospital-(RESEARCH) registry. Catheter Cardiovasc Interv. 2007;70:635-639.
- Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv. 2008;71:8-19.
- Surmely JF, Katoh O, Tsuchikane E, et al. Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv. 2007;69:826-32.
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- Stone GW, Colombo A, Teirstein PS, et al. Percutaneous recanalization of chronically occluded coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc Interv. 2005;66:217-236.
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- McNulty E, Cohen J, Chou T, Shunk K. A "grapple hook" technique using a deflectable tip catheter to facilitate complex proximal circumflex interventions. Catheter Cardiovasc Interv. 2006;67:46-48.
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- 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.
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From the Department of Cardiology, Fukuoka Wajiro Hospital, Fukuoka, Japan.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. No authors reported conflicts regarding the content herein.
Manuscript submitted August 19, 2011, provisional acceptance given September 15, 2011, final version accepted September 27, 2011.
Address for correspondence: Yoritaka Otsuka, MD, FACC, FESC, Department of Cardiology, Fukuoka Wajiro Hospital, 2-2-75, Wajirogaoka, Higashi-ku, Fukuoka 811-0213, Japan. E-mail: firstname.lastname@example.org