AbstractPercutaneous 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
IntroductionPercutaneous 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 TechniqueA 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.
DiscussionThe antegrade advancement of wires through a CTO is not only dependent on the type of wires used, but also on the utilization of several techniques that can enhance procedural success. Guiding catheter support, as well as visualization of the distal vessel, are imperative in the treatment of these patients. As the resistance to penetrate the tough calcified and fibrous cap of a CTO increases, the ability to deliver a device and the need for increased guide catheter “back-up” support increase.4 Attempts to increase force on the wire without extra support results in the guide catheter being pushed back, thereby creating an unstable back-up situation, which may lead to complete dislodgement of the equipment from the target artery.3 In CTOs, many times the Amplatz guides are effective, however, the problem with these guides is that they can cause trauma to the vessel.5 The support balloon or the anchoring balloon technique is effective in these situations (Figure 5).1–3 The balloon-anchoring technique utilizes a standard compliant over-the-wire balloon. The wire and balloon are initially advanced together. Once the balloon is adequately placed proximal to the lesion, the balloon is inflated and then serves as an anchor that provides support for the wire and the guide. With this added support, the wire can be more forcefully directed at the CTO. One variation of this technique is to have the balloon inflated in a side branch such as the conus or the acute marginal branch (Figure 6). This has the obvious advantage of allowing for contrast injection and free, unobstructed access to the CTO. In our case, the positioning of the balloon was at the origin of the vessel. Another variation of this is the Anchor-Tornus technique.6 This technique allows the side-branch balloon inflation technique using the Tornus device (Abbott Vascular) to penetrate resistant lesions. By applying gentle withdrawal pressure to the balloon and forward pressure on the guide, the support-balloon anchoring technique allows for better coaxial positioning and deeper seating of the guide in the target vessel. In general, although this procedure can likely be performed using a 5 Fr catheter, a 7 or 8 Fr catheter is usually preferred. Unlike the retrograde technique, it usually can be performed with minimal contrast utilization and fluoroscopic time. Our patient’s fluoroscopic time was unfortunately 109 minutes, and contrast utilization was 450 cc. However, we encountered more difficulty with balloon inflations, which increased the fluoroscopy time as well as placement of multiple stents and postdilating them for the post-dilatation period.
Potential Complications and Proposed Improvements to the DesignPotential complications include bradyarrhythmias when the balloon is set in the conus branch, trauma to the proximal vessel, barotrauma from the balloon and lack of ability to achieve seating due to the fact that the tip and length of the standard balloon are too long. Some of the complications can be obviated by gentle, low-pressure inflation; however, many times, higher-pressure inflations are necessary. One difficulty is that there are no standard over-the-wire balloons specifically for this technique, and it is our impression that over-the-wire balloons available are too long, do not have an elastomeric balloon and have too long of a tip (Figure 7). We have worked on prototypes that may be more effective for this technique. The balloon is elastomeric, has a shorter tip, as well as a much shorter length — less than 2 mm in tip length and 5 mm in length (Figure 8). In a silastic tube model, we have shown that it is more effective as a support system for crossing a putty-type total occlusion compared to conventional balloons (Sprinter, Medtronic, Inc.) (Figure 9). The balloon size can be dilated to 6 mm and is able to be used in multiple diameters of silastic vessels.
ConclusionIn conclusion, this easy technique using an antegrade approach may be effective in selective patients with CTOs. Anchoring of the guide using a balloon catheter increases support and makes the over-the-wire technique effective in patients where a retrograde technique is not possible or the physician is less experienced. We feel this technique could be improved by making specialized balloons with shorter tips and lengths and with elastomeric material.
1. Hirokami M, Saito S, Muto H. Anchoring technique to improve guiding catheter support in coronary angioplasty of chronic total occlusions. Catheter Cardiovasc Interv 2006;67:366–371. 2. Fujita S, Tamai H, Kyo E, et al. New technique for superior guiding catheter support during advancement of a balloon in coronary angioplasty: The anchor technique. Catheter Cardiovasc Interv 2003;59:482–488. 3. Tsuchikane E. Advanced techniques for antegrade advancement of wires. In: Handbook of Chronic Total Occlusions. United Kingdom: Informa Healthcare. 2007, pp. 23–25. 4. Hamood H, Makhoul N, Grenadir E, et al. Anchor wire technique improves device deliverability during PCI of CTOs and other complex subsets. Acute Card Care 2006;8:139–142. 5. Kawasaki T, Azuma A, Tsukamoto M, et al. Echocardiographically documented acute aortic insufficiency induced by Amplatz left guide catheter. Int J Cardiovasc Intervent 2000;3:237–239. 6. Kirtane AJ, Stone GW. The Anchor-Tornus technique: A novel approach to “uncrossable” chronic total occlusions. Catheter Cardiovasc Interv 2007;70:554–557.
From St. Luke’s Medical Hospital and Medical Center, University of Arizona College of Medicine, Phoenix, Arizona and *Banner Estrella Medical Center, Phoenix, Arizona.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted February 15, 2010, provisional acceptance given April 20, 2010, final version accepted April 27, 2010.
Address for correspondence: Richard Heuser, MD, St. Luke’s Medical Hospital and Medical Center, Clinical Professor of Medicine, University of Arizona College of Medicine, Cardiology, 555 North 18th Street, Suite 300, Phoenix, AZ 85006. E-mail: firstname.lastname@example.org