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258 PART V Interesting Cases

Figure 28.1 (a) Bilateral coronary angiogram showing the long chronic total occlusion (CTO) of the right coronary artery (RCA). (b) Reverse controlled antegrade and retrograde tracking (CART). (c) Externalization of RG3 wire. (d) A 2.5-mm balloon dilatation showing some indentation at the heavily calcified lesion (intravascular ultrasound: IVUS at the site). (e) Stent implantation. (f) A coronary rupture. (g) A Graftmaster covered stent implantation. (h) Final angiogram.

Figure 28.2 (a, b) CTO in the LCX. (c, d) The extended reverse CART. (e) Balloon dilatation after externalization. (f) Final angiogram after stent implantation.

CHAPTER 28 Interesting Cases I–V 259

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illustrates the feasibility of the transradial retrograde approach for CTO through an ipsilateral collateral channel with a single guiding catheter. However, a single guiding system limits the use of the balloontrapping technique in the guiding catheter. In such cases, another guiding catheter may be required.

Case III [1] (Figure 28.3)

Interesting points

Rupture of an iatrogenic aneurysm of a septal branch and subsequent cardiac tamponade during a retrograde approach from the RCA to the CTO lesion in the LAD.

History and PCI procedures

A 79-year-old woman presented with effort angina, which was caused by chronic in-stent occlusion of a bare-metal stent implanted 6 months previously in the proximal LAD. The patient also had a 10-year history of chronic rheumatoid arthritis and was under a maintenance dose of oral prednisolone. The left ventricular

function was normal. PCI was performed using double 7-Fr guiding catheters from both femoral arteries. The retrograde approach was adopted using a combination of a Corsair microcatheter and Fielder FC guidewire through a septal artery from the distal RCA. Both guidewire and microcatheter passage into the LAD distal to the stent occlusion through the septal artery were not difficult. After removing the Corsair microcatheter, we detected aneurysm formation at the septal artery; the aneurysm quickly ruptured spontaneously, causing rapid cardiac tamponade. Under prompt percutaneous pericardiocentesis, the target occlusion was opened and a drug-eluting stent was placed. As bleeding into the pericardial space continued, the ruptured septal artery was embolized using several sets of microcoils from both sides (LAD and RCA). The bleeding completely stopped, and the patient was discharged after several days without sequelae.

It is curious that the septal branch in this case formed an aneurysm and developed spontaneous rupture during smooth and unforced maneuvers to cross the Corsair microcatheter. Long-standing oral

Figure 28.3 (a) Retrograde guidewire passed into the true lumen distal to CTO through a septal branch. (b) After removing Corsair from the septal branch, an aneurysm formation was noted in the septal branch. (c) The aneurysm spontaneously and quickly ruptured. (d) The ruptured artery was embolized by microcoils from LAD and RCA sides under pericardial drainage.

260 PART V Interesting Cases

administration of low-dose steroids may be considered a predisposing factor of this event. Prior to this case, retrograde access through septal channels was thought to be safer than epicardial connections in terms of the risk of cardiac tamponade after arterial rupture. However, this case clearly showed that cardiac tamponade may occur even during the retrograde approach through the septal channels.

Case IV [2] (Figure 28.4)

Interesting points

Isolated left ventricular cardiac tamponade after guidewire perforation of the septal branch during the retrograde approach.

History and PCI procedures

A 64-year-old man was admitted to our hospital for acute inferior myocardial infarction and cardiogenic shock. Emergency coronary angiography showed a TIMI 0 total occlusion in the middle RCA and a CTO lesion in the proximal LAD. The RCA was recanalized using stent implantation.

PCI to the CTO of the LAD was performed in the next stage using two 7-Fr guiding catheters inserted from both femoral arteries. The attempted retrograde access using a Fielder XT guidewire through the second septal branch was unsuccessful because of the acute angle at the junction and LAD. A further attempt to negotiate the acute angle after changing to a Miraclebros 3 guidewire resulted in the perforation of the septal artery at the corner. The patient’s condition was stable after the perforation; therefore, the procedure was continued. A second attempt to cross a guidewire was performed using the first septal branch and was successful. After the CTO lesion in the proximal LAD was successfully opened, the patient developed signs of cardiac tamponade including hypotension and tachycardia.

Portable transthoracic echocardiography revealed a small amount of pericardial free space in the posterior and lateral sides of the left ventricle. Pericardiocentesis was attempted, but no fluid was recovered. Bleeding from the ruptured septal artery was successfully stopped using autologous adipose tissue embolization.

After the patient was transferred to the ICU, profound hypotension continued. Repeat transthoracic echocardiography revealed no increase in the pericardial free space. However, CT revealed a large amount of pericardial free space localized around the lateral sides of the left ventricle. Surgical drainage through a small incision in the subxiphoid space resulted in the recovery of 350 ml of bloody pericardial fluid. The

patient immediately recovered from profound hypotension and was discharged from the hospital 12 days later without sequelae.

This case clearly shows that (i) the retrograde approach through septal channels may result in bleeding into the pericardial space; (ii) if the perforation occurs at the junction between a septal branch and the LAD, pericardial effusion may be localized around the left ventricle; (iii) transthoracic echocardiography cannot detect this localized pericardial effusion; and (iv) urgent surgical pericardial drainage is necessary in this situation.

Case V (Figure 28.5)

Interesting points

Access to the heart in patients with occluded abdominal aorta and left brachial hemodialysis shunt.

History and PCI procedures

A 71-year-old man presented at another hospital with effort angina. The patient had a history of Leriche syndrome and chronic hemodialysis for more than 15 years.

Two years prior to admission, coronary angiography at the previous hospital revealed a CTO lesion in the distal RCA and 90% narrowing of the ramus branch of the LCX. Narrowing of the ramus branch was successfully treated with TRI, but an attempt to open the occluded RCA failed.

The patient was referred to our hospital for recanalization of the CTO in the RCA due to persistent symptoms of angina. Access from both femoral arteries was not possible due to occlusion of the lower abdominal aorta, and access from the left radial/ brachial artery was not feasible because of a hemodialysis shunt.

For the insertion of two guiding catheters using a retrograde approach, two 6-Fr sheath introducers were placed in the right radial and brachial arteries, respectively. A 6-Fr EBU 3.5 and SAL 1.0 guiding catheter were inserted into both the LCA and RCA. The retrograde approach was conducted through a septal branch using a Corsair and Fielder FC guidewire. The CTO lesion was successfully dilated using the anchoring balloon technique. The final results were acceptable.

Alternative access routes are important during PCI for CTO lesions, particularly when using a retrograde approach. PCI operators who manage CTO lesions must be familiar with both radial and brachial approaches, in addition to the standard femoral approach.

CHAPTER 28 Interesting Cases I–V 261

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Figure 28.4 (a) LCA and RCA. (b) Guidewire crossing through the 2nd septal artery and subsequent perforation (arrow). (c) A retrograde guidewire successfully crossed the CTO lesion through the 1st septal artery, and the final result. (d) Transthoracic echocardiography and CT.

262 PART V Interesting Cases

Figure 28.5 (a) RCA and LCA. (b) Retrograde guidewire successfully reached the distal RCA (left) and the lesion was dilated with the utilization of the anchoring balloon technique (left). (c) Final result.

References

1 Hashidomi H, Saito S. Dilation of the septal collateral artery

and subsequent cardiac tamponade during retrograde percutaneous coronary intervention using a microcatheter for chronic total occlusion. J Interv Cardiol 2011; 24: 73–76.

2 Matsumi J, Adachi K, Saito S. A unique complication of

the retrograde approach in angioplasty for chronic total occlusion of the coronary artery. Catheter Cardiovasc Interv 2008; 72: 371–378.

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Index

3D wiring methods 135–155

algorithm 136 antegrade dissection and re-entry 136,

151–155 AnteOwl IVUS-based clinical outcomes 143, 150–151 clinical practice 141–143, 146–147, 148–

150, 152–154 fluoroscopy-based 136–143 guidewire manipulation 135–139, 141–159 indications for approach 140 intraplaque tracking 136, 150 tip detection 136, 144–155 training 139, 147

abdominal aorta, occluded 260 absorption, laser light 189–190, 194 access, retrograde approach 166–167 ACE inhibitors see angiotensin converting

enzyme inhibitors

ACT ONE technology 52–54, 56–58, 84–85,

active calcification 6–7 acute kidney injury (AKI)

contrast-associated 218–231

antioxidants contrast osmolarity 224–225 contrast removal 226–227 contrast volumes 225–226 definition 219 hemofiltration 226 hydration 221–223 mechanical support devices 227 pathophysiology 219 prophylactic measures 221 risk factors 219–221 statins 221

nephrotoxic drugs 221

acute thrombotic occlusion, in-stent 13–14 ADR see antegrade dissection and re-entry AHA see American Heart Association

136, 143–155

223–224

AI see artificial intelligence AKI see acute kidney injury algorithms

antegrade approach with 3d wiring

methods 136 antegrade approaches 136, 159 hybrid 162–163 subintimal angioplasty 123

allograft malignant atherosclerotic

vasculopathy 190–191

alternate routes, transradial intervention 115 American Heart Association (AHA)

guidelines 22–23

Amplatzer vascular plugs 174 anchoring balloon technique 106–107 anchoring stent technique 106 anchoring wire technique 101–103, 117 aneurysm, septal artery 251, 259–260 angiography

success prediction 21 see also fluoroscopy-guided 3D wiring;

imaging

angiotensin converting enzyme inhibitors

(ACE inhibitors) 221

Angled SuperCross microcatheters 79 antegrade approaches

3D wiring indications dual lumen microcatheters 78 general concepts 22 method appraisal algorithm 159 wire escalation 109 see also antegrade dissection and re-entry;

antegrade fenestration and re-entry

antegrade dissection and re-entry (ADR)

129–134, 204–212 balloon-based 130 catheter-based 130–131 contemporary technique 131–132, 204–212 contrast-based 131–132 crossing 209 device-based re-entry 211–212

140

263

264 Index

dissection 206–207 extraplaque space navigation 209–210 imaging 207–208 microcatheters 130–131, 212, 215 outcomes 133, 214 proximal cap disambiguation 207–209 re-entry 210–212 safety 214 STAR technique 123–124 STAR techniques 129–130 tip detection method 136, 151–155 troubleshooting 132–133, 207–209 see also antegrade fenestration

and re-entry

antegrade fenestration and re-entry

(AFR) 130, 133, 156–165, 212–214 benefits of 159–162 development 157–158 dual-guidewire balloons 163–165 facilitated 163–164 failure mechanisms 159 hybrid algorithm inclusion 162–163 indications 158–159 intravascular ultrasound-assisted 163 outcomes data 162 peripheral interventions 165 procedure 158–162 ST segment elevation myocardial

infarction 165 STRAW technique 133, 213–214 tips and tricks 161 troubleshooting 213–214 see also balloon-assisted subintimal entry

antegrade wire escalation (AWE) 109 AnteOwl intravascular ultrasound

(AO-IVUS) 136, 143–155 advantages over Stingray systems 151–152 antegrade dissection and re-entry 136,

151–155 clinical outcomes 150–151 establishment of 143–144 experimental models 147 interventional procedures 146–147,

148–150, 152–154 intraplaque tracking 136, 150 tip detection 144–155

antioxidants, acute kidney injury 223–224 arrhythmias 20 artificial intelligence (AI) 40 assessment

antegrade approach algorithm 159 covered stents 247–248 subintimal angioplasty 121 transradial intervention 120 see also diagnosis

atherectomies

directional coronary 182–183 guidewires 89 orbital 183–184 rotational 181–182, 184, 199–200 SilverHawk Plaque Excision System 183

see also debulking atherosclerotic plaque rupture 5, 14, 16 autopsy studies, pathobiology 3–5 AWE see antegrade wire escalation

Baby Tornus catheters 76–77 balloon-assisted subintimal entry (BASE) 130

power knuckle technique 207–208

side modification 133, 208–209

see also antegrade fenestration and re-entry Bandit guidewires 53–54, 90, 92 bare metal stents (BMS) 4–5, 13–15, 17 bidirectional transradial approach 118–119 bifurcations

dual lumen microcatheters 78, 101, 103

transradial intervention 117

two-wire techniques 101

see also side branches BMS see bare metal stents BMW Universal II guidewires 90 braided microcatheters 70–73 buddy wire technique 106–107

CA-AKI see contrast-associated acute kidney

injury CABG see coronary artery bypass grafts calcification 6–7, 11–12, 29–31, 42–43 cap penetration 64, 67, 92–93, 98 Caravel microcatheter 70, 73 cardiac output deficit (COD) 235 cardiac power output (CPO) 235 cardiac tamponade after guidewire

perforation 260 CART see controlled antegrade and retrograde

subintimal tracking case selection

transradial intervention 120

see also assessment; diagnosis characteristics, microcatheters 70 circulatory support see mechanical circulatory

support classification, tip stiffness 83 clinical findings, chronic occlusions 188 clinical outcomes see outcomes clinical predictors of success 21 coaxial micropumps 227, 233, 235, 238, 241 COD see cardiac output deficit coil-based microcatheters 73–76 coils, saphenous vein grafts 174

Index 265

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collagen 5–7, 29–30 collaterals

crossing 167–168 perforation 170, 251–252

retrograde approach 167–170, 251–252 competitive flow, restenosis 174 complications

laser revascularization 200

mechanical circulatory support 243–244

retrograde approach 170, 250–254

Tornus catheter 65–67 computed tomography (CT) 29–34

antegrade dissection and re-entry 133, 207–208

impacts of 33

pathology representation 30–33

success prediction 21

utility of 29

volume rendering 31–33 Confianza Pro wires 92 confirmation of entrance 35 confluent balloon technique 126, 179 congenital pulmonic atresia 191–192 contemporary antegrade dissection and

re-entry 131–132, 204–212 crossing 209 device-based re-entry 211–212 dissection 206–207 extraplaque space navigation 209–210 imaging 207–208 proximal cap disambiguation 207–209 re-entry 210–212 troubleshooting 207–209

contemporary reverse CART 168–169 contraindications

Impella devices 233 intra-aortic balloon pumps

233 laser revascularization 200 mechanical circulatory support 232–233

contrast media

hemofiltration 226 osmolarity 224–225 removal 226–227 volumes 225–226

contrast-associated acute kidney injury

(CA-AKI) 218–231 antioxidants 223–224 contrast osmolarity 224–225 contrast removal 226–227 contrast volumes 225–226 definition 219 hemofiltration 226 hydration 221–223 mechanical support devices 227 pathophysiology 219 prophylactic measures 221

risk factors

219–221

statins 221

contrast-guided subintimal tracking and

re-entry (contrast-guided STAR) technique 124, 131–132, 210

controlled antegrade and retrograde subintimal

tracking (CART) 104, 124–125 3D wiring 140 confluent balloon technique 126, 179 interesting cases 257 retrograde dissection and re-entry 168 snares 179 tips and tricks 177–180 see also reverse CART technique

controlled-torquing 98 coronary artery bypass grafts (CABG)

clinical implications 15–17 electrosurgical recanalization 174–175 histopathology 10–13 imaging 173 laser revascularization 199 pathobiology 3–4 reduction in need 20–21 restenosis 174 retrograde approach 172–176

coronary perforation

collaterals 170, 251–252 covered stents 246–249

Corsair microcatheters 73–74, 110 Corsair Pro microcatheters 73–74 Corsair Pro XS microcatheters 74–75 covered stents 246–249

deployment 247–248 optimization 247–248 outcomes 248 sizes

247 special considerations 248 types 246

CPO see cardiac power output cross vein graft occlusions 173–174, 174 CrossBoss catheter 126, 130–131 crossing

antegrade dissection and re-entry 209 collaterals 167–168 optical coherence tomography 40–41 retrograde 104–106, 168 Tornus catheter support 65 two-wire benefits 101–103

CT see computed tomography cutting balloon angioplasty 157

DCA see directional coronary atherectomy de-escalation 98–99 debulking 181–185

directional coronary atherectomy 182–183, 184

266 Index

DOCTORS study 184 lasers 187–203 orbital atherectomy 183–184 outcomes 184 role of 184 rotational atherectomy 181–182, 184, 199–200 SilverHawk excision system 183

synergistic laser procedures 199–200 delivery, covered stents 247–248 DES see drug eluting stents diagnosis

antegrade approach algorithm 159

of chronic occlusions 188

subintimal angioplasty 121

transradial intervention 120

see also assessment directional coronary atherectomy (DCA)

182–183, 184 directional microcatheters 79–80 dissection and re-entry (DR), guidewires 94 distal fibrous cap 5, 112 DLMC see double-lumen microcatheters DOCTORS (Debulking of CTO with

Rotational or Directional Atherectomy

before Stenting) study 184 donor artery injuries donor vessel management 167 double-lumen microcatheters (DLMC) 77–79,

101, 103

antegrade fenestration and re-entry 159 parallel-wire technique 111

transradial intervention 115 drilling technique 98 drug delivery 78 drug eluting stents (DES) 4–5, 13–15, 17, 182 dual lumen microcatheters see double-lumen

microcatheters dual-guidewire balloons 163–165 DyeVert Plus EZ Contrast Reduction System 227

ECMO see extra corporeal membrane

oxygenation edge dissections, stents 44 EF see ejection fraction efficacy see outcomes ejection fraction (EF), left ventricular 20 ELCA see excimer laser coronary angioplasty electrocardiogram-gated cardiac computed

tomography 21 electrosurgical recanalization 174–175 entry points, intravascular

ultrasound-guided 35–36 epicardial perforation 170, 251–252 ESC see European Society of Cardiology

escalation of guidewires 98–99 European Society of Cardiology (ESC)

guidelines 22–23 exchanging wires, parallel-wire technique 112 excimer laser coronary angioplasty

(ELCA) 190, 195–199 extension catheters 106 externalization

CART techniques 179 guidewires 89–90, 94–95 retrograde approach 170 reverse CART 179

extra corporeal membrane oxygenation

(ECMO) 236 extraplaque space navigation 209–210

facilitated antegrade fenestration and

re-entry 163–164 facilitated antegrade steering technique in chronic

total occlusions (FAST-CTOs) trial 126 failures

antegrade fenestration and re-entry 159 reverse CART technique 169

FAST-CTOs trial see facilitated antegrade

steering technique in chronic total

occlusions trial femoral artery, transradial intervention 115 fibrin 5–7, 10–11 Fielder FC guidewires 52–53 Fielder XT guidewires 53, 55, 90–91, 94, 96,

101–103 Fighter wire 53, 55, 90, 92 FineCross microcatheters 70–73, 110 finger manipulation 97 fluoroscopy-guided 3D wiring 136–143

clinical outcomes 143 clinical practice 141–143 image construction 136–139 indications for approach 140

training 139 four P’s, optical coherence tomography 39–40 Fujino scores 43

Gaia guidewires 55–59, 93, 178 Gaia Next guidewires 59, 93–94 gf see gram-force measurement Gladius guidewires 53, 56 Gladius Mongo ES guidewires 53–54, 56 Gladius Mongo (Gladius MG) guidewires

53–54, 56, 94, 96 GraftMaster stents 246–247 gram-force (gf) measurement 83–84 guide-extension reverse CART 168–169, 178 GuideLiner 178

Index 267

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guidelines 22–23 guides, retrograde approach 167 guidewires

cap penetration 92–93 clinical use cases 90–95 collateral crossing 167 de-escalation 98–99 dissection and re-entry 94 electrosurgery 175 escalation 98–99 externalization 94–95 intraplaque navigation 93, 98, 136, 150 knuckling 94, 96 lubricity 84–86 manipulation techniques 97–98 microchannel navigation 90–92 retrograde approach 93–94 septal entrapment 252–253 shaping 96–97 tactile feedback 97 targeting 90 tip stiffness 97

see also wires… Guidezilla 178 guiding catheters, transradial intervention 117–118

hematoma, septal artery 251, 259–260 hemodynamic collapse

mechanical support 232–245

risk factors 232–235 hemodynamic effects, mechanical circulatory

support 235–236 hemofiltration 226 high-osmolar contrast media (HOCM) 224 histopathology 10–15, 187–188, 203

acute thrombotic occlusion, in-stent

13–14 clinical implications 15–17 coronary artery bypass grafts 10–13 in-stent 13–15 neoatherosclerotic plaque rupture 14, 16 restenosis 14–15

HOCM see high-osmolar contrast media Hornet guidewires 59, 61, 92 human studies, pathobiological 3–5 hybrid algorithm 162–163 hydration, contrast-associated acute kidney

injury 221–223

hydrophilic coatings 49, 84–85

IABP see intra-aortic balloon pumps iatrogenic occlusions

interesting cases 257–262 post-arterial bypass 4

ICT see inner coil technology

imaging

29–45 angiography-guided 3D wiring 136–143 antegrade dissection and re-entry 133,

207–208 AnteOwl intravascular ultrasound 143–155 computed tomography 29–34 intravascular ultrasound 35–38, 143–155 optical coherence tomography 39–45 stent efficacy 44 success prediction 21 vein grafts 173

Impella devices 227, 233, 235, 238, 241 in-hospital outcomes 22 in-stent chronic total occlusions (IS-CTO)

acute thrombotic occlusion 13–14 clinical implications 17 etiologies 13, 17 histopathology 13–15 laser revascularization 199 neoatherosclerotic plaque rupture 14, 16 pathobiology 4–5 restenosis 14–15

indications 19–21

antegrade fenestration and re-entry 158 laser revascularization 195–196 mechanical circulatory support 232–233,

236–237, 242–243 plaque debulking 181 retrograde approach 166 TandemHeart device 233

Infiltrac Plus wires 92 Infiltrac wires 92 inflammation, occlusal formation 5 infra-red lasers 190 inner coil technology (ICT) 84–85 interesting cases

257–262 intermediate stiffness guidewires 88–89 intra-aortic balloon pumps (IABP) 232–233,

235, 238, 240–241

intraluminal microvessels

formation 6 see also recanalization channels

intraplaque navigation

AnteOwl intravascular ultrasound 136, 150 controlled-torquing 98 guidewires 93

intravascular ultrasound (IVUS) 35–38

antegrade dissection and re-entry 133, 136,

151–155, 207–208 antegrade fenestration and re-entry 163 AnteOwl device 136, 143–155 directional coronary atherectomy 182–183 guiding at CTO entrance 35–36 intraplaque tracking 136, 150

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