Disclosure: Dr. Heuser reports he is a co-developer of the CrossLock Catheter and Prodigy Support Catheter.
Dr. Richard Heuser can be contacted at email@example.com.
Dr. Pancholy recently discussed enhanced guiding support techniques for performing coronary chronic total occlusion (CTO) recanalization.1 When an interventionist approaches either a peripheral or coronary chronic total occlusion, it is important to attempt to keep the wire in the lumen of the vessel in order to have a higher likelihood of recanalizing the chronic occlusion. Stiffness of the wire is important in crossing the lesions, but support of the catheter through which the wire is placed is imperative. Unfortunately, this can result in significant trauma to the coronary artery in the case of a coronary lesion. Treating a peripheral CTO usually is difficult primarily because there is a paucity of safe support catheters that supply enough support to stabilize the catheter while traversing the occlusion with the wire. The anchoring technique has improved guiding catheter support with a reduced likelihood of guiding catheter dissection.2,3 We recently described another option in patients where guiding catheter support is insufficient, the Prodigy support catheter (Figure 1).4–6 We now present an example of another support catheter for coronary artery and peripheral vascular disease, the CrossLock catheter (Figures 2-3) (Radius Medical). The following cases describe its utilization.
Case 1. A 67-year-old gentleman who we have managed for the last 15 years recently presented with a recurrence of a right coronary CTO. He originally underwent coronary revascularization in 1990. At that time, he had documentation of a right coronary CTO, and with recurrence of symptoms and graft failure, he underwent a second coronary artery bypass graft surgery in 1997. Shortly thereafter, his right coronary artery (RCA) graft again occluded and after unsuccessful RCA percutaneous coronary intervention, with no percutaneous or bypass option available to recanalize the RCA, he underwent surgical transmyocardial revascularization (TMR). Following this, attempts to revascularize the RCA were unsuccessful; however, he continued to have well maintained left ventricular (LV) function and had a patent saphenous vein graft to the circumflex and internal mammary graft to his left anterior descending coronary artery (LAD). In December 2010, we were able to finally recanalize his RCA, using the anchoring balloon technique, and for the first time in over 20 years, he had complete angina relief. In the fall of 2013, the patient had recurrence of angina and had successful recanalization of the previously deployed stents. In January 2015, he presented with increased angina. He was on maximally tolerated antianginal medications and had normal LV function and inferior ischemia noted with exercise. After the abnormal myoview and continued angina with minimal activity, we performed an angiogram. He had a re-occlusion of the RCA with left to right collaterals to the posterior descending branch of the RCA via the LAD. We attempted both antegrade and retrograde approaches using the hybrid technique. With the standard over-the-wire (OTW) anchoring balloon, however, we were not able to recanalize, and using the retrograde approach, we could not pass across the distal portion of the posterior descending artery of the RCA. We brought him back 1 month later with the availability of the CrossLock catheter (Figure 4).
The CrossLock catheter at this time requires an 8 French (Fr) guiding catheter. The CrossLock catheter, which is .014-inch compatible, was passed over a Miracle 3 wire (Abbott Vascular). The CrossLock catheter has a distal elastomeric balloon that centers the catheter in the blood vessel, theoretically making passage of the wire across the CTO more likely to be successful. The patient’s radial artery, although still patent, did not give sufficient support with guiding catheters, so we accessed his RCA via the right groin. We used an Amplatz left (AL)2 (8Fr) guiding catheter and a Miracle 3 wire, and a .9mm laser catheter (Spectranetics). Unlike with the previous anchoring balloon attempt, with the CrossLock balloon inflated in the origin of the CTO, this very firm support allowed us to immediately cross the CTO and after passing the wire, utilize the laser (Figure 5-7). Since the patient has had multiple stents, we did not place any further stents, but performed laser recanalization and balloon angioplasty with focused balloons (Figure 8). As with the initial successful recanalization of this old CTO, we were satisfied with recanalization of only the posterior descending branch (Figures 9-10).
This gentleman has undergone multiple procedures, but is otherwise very healthy. With surgery, whether with grafts or TMR, he has never had relief of his angina, but PCI, when successful, has always relieved his angina, even though at times it was short lived. When we opened the CTO 5 years prior, the posterior descending branch was recanalized and he had complete angina relief. At 4-month follow-up, the patient is now completely angina free.
Case 2. The second patient presented with critical limb ischemia of her left leg. A left femoral angiogram revealed a 100% occlusion below the popliteal artery (Figure 11). We placed an 8Fr Ansel catheter (Cook) in the proximal superficial femoral artery. The CrossLock catheter was placed over a Command wire (Abbott Vascular) and the CrossLock balloon was dilated (Figure 12). The CTO was navigated with the wire passing into the peroneal artery. We were able to maintain the CrossLock balloon in a dilated position as we crossed with a 3mm x 60mm balloon (Abbott Vascular) (Figure 13). Following balloon inflation, we placed a second wire across the anterior tibial occlusion and performed kissing balloon inflation with two AngioScore balloons (Spectranetics) (Figure 14). With a continued dissection at the peroneal anterior tibial junction, we placed two 3mm x 40mm drug-eluting stents (Abbott Vascular) (Figure 15). The patient now has rapid 2-vessel runoff to the foot. One month after the procedure, she is pain free.
Over the last 25 years, there have been improvements in both antegrade and retrograde techniques to treat CTOs, including new guide wires, microcatheters and even balloons dedicated to this approach.7-12 We have found that the antegrade technique, whether used in conjunction with the retrograde approach or on its own, has been enhanced by the availability of the Prodigy balloon. The CrossLock appears to combine excellent support as well as the ability to pass lasers or support catheters to treat not only coronary CTOs, but potentially aid in any complex native or saphenous vein graft intervention. In peripheral applications, the anchoring balloon in the CrossLock, similar to the Prodigy, seems to center the wire access, potentially making it less likely to go into the subintimal space and result in a vessel dissection. When we cross CTOs in the peripheral vessels, the support catheters, up until this time, have never been an active participant. With the elastomeric balloon in the CrossLock, we have an improvement in support, allowing other adjunctive devices to be passed with more ease. We look forward to further experience with these two new devices in our armamentarium to treat both coronary as well as peripheral CTOs and complex lesions.
- Palancholy S. Enchancing guide support during a complex coronary intervention via transradial approach. Cath Lab Digest. 2014 June; 22(6). Available online at http://www.cathlabdigest.com/articles/Enhancing-Guide-Support-During-Complex-Coronary-Intervention-Transradial-Approach. Accessed September 23, 2015.
- 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 Aug: 9(4): 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.
- Heuser RR. Same problem, different solution. Cath Lab Digest. 2015 May; 22(5). Available online at http://www.cathlabdigest.com/article/Same-Problem-Different-Solution. Accessed September 23, 2015.
- Moualla SK, Heuser RR. The utility of the Prodigy™ balloon in chronic total occlusion. Vascular Disease Management Blog, May 2014. Available online at http://www.vasculardiseasemanagement.com/blog/utility-prodigy-balloon-chronic-total-occlusion. Accessed September 23, 2015.
- Moualla SK, Khan S, Heuser RR. Anchoring improved: introduction of a new over-the-wire support balloon. J Invasive Cardiol. 2014 Sept; 26(9): E130-E132.
- Kahn JK, Hartzler GO. Retrograde coronary angioplasty of isolated arterial segments through saphenous vein bypass grafts. Cathet Cardiovasc Diag. 1990; 20: 88-93.
- Surmely JF, Tsuchikane E, Katoh O, et al. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique. J Invasive Cardiol 2006; 18: 334-338.
- Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv. 2008; 71: 8-19.
- Kimura M, Katoh O, Tsuchikane E, et al. The efficacy of a bilateral approach for treating leions with chronic total occlusions the CART (Controlled Antegrade and Retrograde Subintimal Tracking) registry. JACC Cardiovasc Interv. 2009 Nov; 2(11): 1135-1141. doi: 10.1016/j.jcin.2009.09.008.
- Tsuchikane E, Katoh O, Kimura M, Nasu K, Kinoshita Y, Suzuki T. The first clinical experience with a novel catheter for collateral channel tracking in retrograde approach for chronic coronary total occlusions. JACC Cardiovasc Interv. 2010 Feb; 3(2): 165-171. doi: 10.1016/j.jcin.2009.10.026.
- Tomasello SK, Gludice P, Attisano T, Boukhris M, Galassi AR. The innovation of composite core, dual coil coronary guide-wire technology; a didactic coronary chronic total occlusion revascularization case report. J Saudi Heart Assoc. 2014; 26: 222-225.