Cath Lab Digest

Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI and John E. Lassetter, MD, FACC, FSCAI

This 70-year-old gentleman was told his right coronary artery (RCA) had been 100% occluded for 6 years. He presented with continued angina and ischemia not only in the inferior territory but also the lateral territory. His risk factors for coronary disease include hypertension, hyperlipidemia and known chronic occlusion of his RCA for the last 5 to 6 years.

Angiography showed that a total occlusion of the obtuse marginal was present; multiple injections with several catheters were unable to visualize the RCA. There was no antegrade filling of the RCA with multiple catheters. Aortic root injection did not allow visualization of the origin of the vessel. By observing collaterals, it was clear that the RCA was 100% occluded. The patient was enrolled in the FAST CTO study to treat the circumflex artery chronic total occlusion (CTO). With difficulty torqueing the catheter, a long 65 cm Arrow 7 Fr sheath (Arrow International, Cleveland, Ohio) was placed and we used an EBU (Medtronic, Inc., Minneapolis, Minnesota) curve in a Transit catheter (Cordis Corp., Miami Lakes, Florida). After 10 minutes of wiring, we were unsuccessful with a Miracle 3 wire. The CrossBoss was used, and we were able to cross the CTO at first using the Miracle 3 (Abbott Vascular, Abbott Park, Illinois), and then the Fielder XT (Abbott Vascular, Abbott Park, Illinois). Several inflations with a 1.5 x 5 mm balloon were performed, followed by successful placement of several Xience 2.5 x 8 mm, 2.5 x 12 mm, and 2.5 x 12 mm stents (Abbott Vascular). At the end of the procedure, TIMI 3 flow was noted.

The patient was brought back 30 days later for recanalization of the RCA via the right radial artery. A 5 Fr sheath was placed in the left groin, and a diagnostic catheter was placed for simultaneous injections. A JR4 was placed after multiple attempts to visualize the RCA. We were successful with a multipurpose catheter, showing that there was an aberrant takeoff of the RCA with a very straight proximal segment that looked like a bypass graft.

Once the diagnostic study was performed, a Transit catheter was placed, followed by a Miracle 3 wire and then a Fielder XT to cross the 100% occlusion. We exchanged for the Miracle 3 wire to perform balloon angioplasty in several drug-eluting stents with the Xience stents. This 6-year-old occlusion was successfully recanalized.

This is a case where using the radial approach allowed us to visualize the RCA — something that was not possible from the right groin. Our site is now doing radial-first procedures unless there is a contraindication. There has been increasing experience with the radial approach in the treatment of CTOs. In this case, with excellent guiding catheter support, the procedure was actually quite easy, and the CTO was easily recanalized, even though it was 6 years old.

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Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, is an internationally-recognized cardiologist, inventor, educator and author. A diplomate of the American Board of Cardiovascular Diseases and American Board of Interventional Cardiovascular Diseases, Dr. Heuser is one of the early pioneers of angioplasty and is considered one of America’s top cardiologists. Dr. Heuser is currently in practice at the Phoenix Heart Center/Physicians Group of Arizona. He is Chief of Cardiology and Chief of Cardiac Catheterization Laboratory at St. Luke’s Hospital and Medical Center, Phoenix, Arizona, and Clinical Professor of Medicine at the University of Arizona College of Medicine, as well as Director of the Interventional Fellowship Program at the University of Arizona College of Medicine, Phoenix Campus.

With 13 patents granted for different catheters, stents and other medical devices, Dr. Heuser has served as principal investigator to research the safety and/or effectiveness of more than 100 medical devices and 70 pharmaceutical products, and has participated in more than 150 research studies. He has authored over 400 articles, textbooks and medical manuscripts, and is frequently invited to international medical conferences to present the findings of research developed in Phoenix.

Dr. Heuser received his medical degree from the University of Wisconsin School of Medicine in Madison, Wisconsin, and completed his medicine internship and residency, as well as his cardiology fellowship, at The Johns Hopkins Hospital in Baltimore, Maryland.