Support Comes From Many Directions
- Fri, 1/6/12 - 3:37pm
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A 65-year-old male presented with angina pectoris. Five months prior to this procedure, attempted recanalization of his right coronary artery was performed unsuccessfully. He presented with recurrent angina. His risk factors included hyperlipidemia and diabetes mellitus. He also had a previous PTCA of the ramus in 2008. The patient’s right coronary artery showed ipsilateral collaterals and a right radial approach was attempted. We did not place a contralateral catheter. After local anesthesia, radial access was performed and the 5 Fr diagnostic Jacky™ catheter was inserted through the 6 Fr sheath. For recanalization of the right coronary artery, a 6 Fr Ikari right 2.0 guide catheter was utilized. The wire was inserted through the guiding catheter; however, due to poor guide support, a Sprinter® over-the-wire balloon was inflated proximally. The wire was then passed across the proximal portion of the CTO. We exchanged the balloon catheter for a FineCross™ support catheter and after further advancement of the wire, it was exchanged for a Fielder XT wire. The Fine Cross was exchanged for a 1.25 x 6 mm over-the-wire balloon and we switched to the GuideLiner system due to continued poor support. Next, the Sprinter® Legend balloon was passed with GuideLiner support and multiple balloon inflations. We then placed 6 Endeavor stents; 3.0 distally up to 3.5 proximally. It was clear there was thrombus present in the vessel so we passed a Whisper wire across the total occlusion distally and the Export® catheter was advanced with clot removed. Activated clotting times (ACTs) were followed and were over 200 with repeated doses of heparin. At the end of the procedure TIMI III flow was obtained. There was 0% residual stenosis. We performed radial compression and the stenosis went from 100% to 0%.
This is a case where the guiding catheter support with an anchoring balloon was effective, but was not as effective as utilization of the GuideLiner to further cross the 100% occlusion. In many CTOs, we also use aspiration because even though this appears to be a chronic occlusion, sometimes thrombus is present at the end of the procedure. It is important to make sure that you follow ACTs on a 30-minute basis and utilize such thrombus aspiration catheters as the Export®, which was used effectively in this case. The patient is now 2 months post-procedure, free of angina.
Product credits:Jacky™ catheter, Ikari guide catheter, FineCross™ support catheter (Terumo Medical)
Provia wire, Sprinter® Legend RX Semicompliant Balloon and Semi-Compliant Over-the-Wire Balloon Dilatation Catheter, Export® AP Aspiration Catheter (Medtronic Medical)
Fielder XT wire, Hi-Torque Whisper (Abbott)
GuideLiner system (Vascular Solutions)
Figure 1. The RCA in a LAO projection is totally occluded.
Figure 2. The RCA with the anchoring balloon in place with passage across the proximal cap of the CTO.
Figure 3. The CTO is still being crossed for further support with the GuideLiner.
Figure 4. The GuideLiner has allowed completed crossing of the CTO.
Figure 5. The RCA prior to the use of the Export® catheter.
Figure 6. Final angiogram after stenting.
Figure 7. Distal recanalized RCA after stenting.
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