This article received a double-blind peer review from members of the Cath Lab Digest Editorial Board.
Chronic total occlusion (CTO) intervention is frequently thwarted by unsuccessful guide wire crossing. Another challenge is balloon catheter delivery across the stenosis, which may be hindered by lesion characteristics such as tortuosity or calcification. This report describes intervention on a 73-year-old female with significant left main and triple-vessel coronary artery disease. We describe the sequence of multi-vessel intervention on the left main, obtuse marginal and left anterior descending CTO. Success in this case depended on application of the anchor balloon technique to deliver the balloon catheter for initial dilatation after successful crossing of the CTO with the guide wire.
A 73-year-old female with end-stage renal disease presented to the emergency department with worsening shortness of breath and chest pain since her last hemodialysis treatment 5 days prior. Her other medical co-morbidities include hypertension, diabetes mellitus, dyslipidemia and congestive heart failure. An electrocardiogram showed only non-specific T wave abnormalities; however, the troponin I level was elevated. Echocardiography showed normal left ventricular function, but due to her history of frequent chest pain with hemodialysis, we recommended an invasive management strategy.
Coronary angiography showed a 70% stenosis of the proximal second obtuse marginal branch (Figure 1), 60% ostial left main stenosis, and total occlusion of the mid left anterior descending coronary artery (LAD) (Figure 2) with distal filling from left-to-left collaterals. The right coronary artery was patent, but had severe diffuse distal disease extending into the posterior descending branch and the posterolateral segment (Figure 3). The cardiothoracic surgical team judged her to be a poor operative candidate due to high risk (operative STS [Society of Thoracic Surgery] mortality risk of 11.2% and morbidity/mortality risk 45%) and poor target vessels. The patient and family decided to proceed with percutaneous coronary intervention despite the high risk (SYNTAX score of 56, four-year major adverse cardiac and cerebrovascular event rate [MACCE] of 40.1%).
A 6 French Judkins Left 4 guide catheter was used to engage the left main coronary ostium. A balanced-middleweight Universal guidewire (Abbott Vascular) was advanced down the circumflex coronary. The ostial left main stenosis was pre-dilated with a 3.0 x 8 mm Emerge compliant balloon (Boston Scientific) and then stented with a 3.0 x 8 mm Ion paclitaxel-eluting stent (Boston Scientific). The guidewire was advanced into the second obtuse marginal branch and the proximal stenosis was directly stented with 2.25 x 15 mm Ion stent. After ensuring an adequate result for the left main and obtuse marginal targets (Figure 4), we proceeded to tackle the LAD CTO.
A Fielder XT (Abbott Vascular) guide wire successfully crossed the LAD CTO, but required the support of a 1.5 x 6 mm Sprinter over-the-wire balloon (Medtronic). Attempts to advance this low-profile balloon through the occlusion were unsuccessful and resulted in disengagement of the guide catheter, despite deep seating. We resorted to the anchor balloon strategy, placing 2.5 x 12 mm Emerge balloon within the second obtuse marginal stent.
Expanding this balloon to a nominal pressure of 8 atmospheres provided a very stable support base, allowing facile advancement of the Sprinter balloon through the CTO (Figure 5). After adequate pre-dilatation, a 2.5 x 32 mm Ion stent was placed, yielding a reasonable result in a diffusely diseased LAD (Figure 6). The patient had an uneventful post-procedural course and was seen in follow-up several weeks after discharge.
Since Fugita et al1 first published the anchor balloon technique in 2003, several case reports can be found in the literature citing usage in complex interventions. Hirokami and colleagues published a report in 2006 describing the use of the anchor technique for CTO intervention.2 Recently, Mahmood et al3 presented several cases describing successful application of a variation of the originally described technique, in which a balloon is inflated distal to the target lesion to provide the anchor to deliver the interventional device. Pervaiz and Laham4 made an insightful commentary regarding the potential for vessel injury that may complicate this technique, arguing that it should be a technique of last resort and other considerations such as proper guide selection may obviate its need.
In this case report, we describe application of the originally described side branch anchor technique1, but with some unique aspects. The relatively short left main would likely not have allowed advantageous placement of the GuideLiner support catheter (Vascular Solutions). The same reason would likely have disadvantaged the “mother-child” coaxial guide catheter technique5; thus, these techniques were not attempted. The second obtuse marginal stent provided a risk-free target site for the side branch anchor balloon. This was a fortuitous circumstance, allowing employment of the side branch anchor balloon technique without risk for intimal injury from balloon inflation. The inflated balloon in the side branch provided an “anchor” or stable base for advancement of a balloon through the CTO. Joyal and colleagues6 published a meta-analysis of 13 observational studies comparing outcomes after successful vs. failed CTO re-canalization attempts, encompassing 7,288 patients observed over a weighted average follow-up of 6 years. In this meta-analysis, successful attempts appear to be associated with an improvement in mortality and with a reduction for the need for CABG as compared to failed re-canalization.6 In the 6 studies that reported angina status, successful re-canalization was associated with a significant reduction in residual or recurrent angina.6 With accumulating evidence for benefit and improved reimbursement with a dedicated billing code for CTO intervention, perhaps we may see a rise in the rate of CTO intervention attempts. A review article by Grantham et al7 discusses various antegrade (parallel-wire, see-saw) and retrograde (CART, reverse CART, kissing wire) techniques to cross the lesion with the guide wire. Coaxial anchoring5, in which a balloon is inflated proximal to the CTO to provide additional support for guidewire penetration, should be added to this repertoire. After successful wire crossing, delivery of a dilatation balloon or even an exchange catheter may still be a significant limitation, as it was in this case. Before abandoning the effort and retreating to the solace of medical therapy for management of a recalcitrant CTO, one should explore the suitability of the side branch anchor balloon technique.
- Fujita S, Tamai H, Kyo E, Kosuga K, Hata T, Okada M, 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.
- 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.
- Mahmood A, Banerjee S, Brilakis ES, et al. Applications of the distal anchoring technique in coronary and peripheral interventions. J Invasive Cardiol. 2011; 23: 289–292.
- Pervaiz M, Laham R. Distal anchoring technique: yet another weapon for successful intervention. J Invasive Cardiol. 2011; 23: 293-294.
- Di Mario C, Ramasami N. Techniques to enhance guide catheter support. Catheter Cardiovasc Interv. 2008; 72: 505–512.
- Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis. Am Heart J. 2010; 160(1): 179–187.
- Grantham JA, Marso SP, Spertus J, House J, Holmes DR, Rutherford BD. Chronic total occlusion angioplasty in the United States. J Am Coll Cardiol Intv. 2009; 2; 479-486.