Cath Lab Digest

Abstract

Percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) remains a challenge for the interventional cardiologist. The introduction of novel techniques has greatly enhanced procedural success. One technique includes the use of a support balloon to improve guiding catheter support during recanalization of the coronary artery. We present a case report of a male who had a 100% occlusion of his right coronary artery for the last 27 years that we successfully recanalized. We also propose changes to the current balloon design that would potentially reduce complications with this technique.

VASCULAR DISEASE MANAGEMENT 2010;7:E171–E174

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Introduction

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) continues to be a technical challenge for interventional cardiologists. In an attempt to improve the success rates, several novel PCI techniques have been developed including “parallel” and “see-saw” wire techniques, subintimal tracking and re-entry (STAR), retrograde techniques, contralateral injection and use of intravascular ultrasound (IVUS) guidance. Guiding catheter support as well as visualization of the distal vessel are imperative for treating these patients. Guiding catheter support, even with Amplatz™ guide catheters (Boston Scientific Corp., Natick, Massachusetts), is somewhat difficult and has been helped by the support-balloon technique in many patients.^1–3 However, there are a few potential complications associated with this method. We present the case of a patient who had a 100% occlusion of his right coronary artery (RCA) for the last 27 years that was successfully recanalized by utilizing the support-balloon technique. We also propose changes to the current balloon design that would potentially reduce complications associated with this method.

Case Presentation and Technique

A 67-year-old male underwent coronary artery bypass graft (CABG) surgery in 1983. At that time, it was documented that his RCA was 100% occluded. Because of the recurrence of angina in 1990, CABG was repeated. His coronary risk factors included hypertension, diabetes mellitus and hyperlipidemia. Two weeks prior to admission, he underwent diagnostic cardiac catheterization because of continued chest pain. His left ventricular size was normal, with a small area of apical hypokinesis at the tip of the apex and an ejection fraction of 60%. The RCA was 100% occluded (Figure 1); the left main coronary artery (LMCA) had minimal plaque, the left anterior descending artery (LAD) was totally occluded at its origin, and the left circumflex artery (LCX) was widely patent, with a previously deployed stent that was widely patent. The internal mammary graft to the distal LAD was widely patent, with a 20% stenosis at the anastomosis. The patient had been on ranolazine at 500 mg twice daily. This dose was doubled. He presented 2 weeks later with continued angina. Because of the 100% occlusion of his RCA — the etiology for his pain he has experienced ever since his original surgery in 1983 — he underwent attempted recanalization. The patient underwent bilateral access of the left and right groin arteries. A 6 Fr diagnostic catheter was placed to allow contralateral injections of the left system to visualize the collaterals to the distal right. The LAD was occluded and there were no significant septal branches forming retrograde to the collaterals. The patient was given 6,000 units of heparin, and an AR1 (Amplatz right) 8 Fr guide was used, along with a 3.0 x 10 mm long Sprinter™ balloon (Medtronic, Inc., Minneapolis, Minnesota) for guiding catheter support (Figure 2). Without the over-the-wire balloon support, the guiding catheter continued to be expressed outside the RCA. With a Miracle 3™ wire (Abbott Vascular, Santa Clara, California), minimal passage was possible into the CTO and the total occlusion was able to be crossed with the Confianza™ wire (Abbott Vascular). The over-the-wire balloon was removed and the catheter was exchanged for a Transit™ catheter (Cordis Corp., Bridgewater Township, New Jersey). A Terumo Gold wire (Terumo Medical Corp., Somerset, New Jersey) was then placed into the distal portion of the RCA (Figure 3). The Terumo Gold wire was exchanged for a Whisper™ wire (Abbott Vascular) and after balloon dilatation, 3.0 x 12 mm, 3.0 x 30 mm Endeavor® stents (Medtronic) were placed, and at the ostium, a 3.5 x 15 mm Endeavor® stent (Medtronic) was placed. Diminished flow was resolved by further balloon inflation and intracoronary nicardipine. The total occlusion went from 100% to a widely patent vessel with no stenosis (Figure 4).

The Mynx™ device (AccessClosure, Inc., Mountain View, California) was used to close the left side. The arterial catheter was maintained in the right side and the sheath was manually removed 3 hours later. The patient has been home for 3 months and has been free of angina.