Editor's note: Videos are available with this case. The list can be accessed at CLD's multimedia page or individually in the text below.
A recent case study in Cath Lab Digest discussed the use of guide catheter extensions such as the GuideLiner (Teleflex) and the GuideZilla (Boston Scientific) as often necessary tools to assist in traversing difficult anatomy for the successful completion of complex percutaneous coronary intervention (PCI).1 We recently reported our results using the CrossLock catheter (Radius Medical) as a guide catheter extension for complex coronary PCI, with a possible advantage resulting from its design as a centering catheter used for chronic total occlusions (CTOs). The CrossLock also has active support for crossing complex lesions (Image 1A-C).2 When used for a non-crossable but wireable stenosis, the CrossLock catheter’s support permits crossing with balloons, lasers, or stents. We found the CrossLock to be uniquely suited to offer extra support with an atraumatic elastomeric balloon tip in the child portion of the device (Image 1A-C).
Despite the success of coronary support catheters, innovation has lagged in the development of peripheral support catheters. We present a case that describes an additional application of the CrossLock catheter. In this case, we first access a superficial femoral artery (SFA) total occlusion via an antegrade approach using a standard sheath. The balloon anchoring feature of the CrossLock allows us to use its centering feature to cross the CTO, and at the same time, an inner support catheter can be passed, allowing a wire exchange. The ease of use of the device is demonstrated in the following case, where the CrossLock was used for the first time by a fellow at the beginning of a complex PCI fellowship.
A 65-year-old gentleman who works as a vendor at a sports stadium noted difficulty going up and down the stairs due to pain in his left calf. After seeing a vascular surgeon who ordered non-invasive testing and noted his 100% SFA occlusion, he was told that his symptoms were not severe enough for femoral-popliteal bypass, and that the surgeon did not feel balloon angioplasty or stenting were appropriate. Since conservative therapy was recommended, she started him on cilostazol 100 mg/day. His claudication did not improve over 2 months, and he presented for treatment because of his frustration with his continued symptoms. His risk factors included a 50-pack-year smoking history.
We initially performed a diagnostic study and treated his right iliac artery with a stent via the right radial artery. The patient then presented for intervention on his left leg via an antegrade approach (Figure 1, Video 1). Using ultrasound guidance, a 6 French (Fr) sheath was placed in the left groin and the patient was heparinized. The CrossLock support catheter was passed over a .014-inch Command wire (Abbott Vascular). Since the CrossLock is an over-the-wire catheter, a Finecross (Terumo) was used to allow for easy wire exchanges. The total occlusion was crossed approximately two-thirds of the way with the Command wire (Figures 2-3, Video 2, and VIdeo 3). We exchanged for a Whisper wire and fully crossed the lesion (Figure 4, Video 4). We injected through the Finecross after removing the Whisper wire, confirming we were in the distal popliteal vessel. The lesion was fairly densely calcified, so we decided to pretreat the lesion with a Diamondback 2.0 atherectomy catheter (CSI) (Figure 5, Video 5). This size crown does not fit through the CrossLock, so, with wire access, we removed the CrossLock. After 5 passes at 60,000 rotations per minute, the CSI catheter was removed, patency confirmed (Figure 6, Video 6), and then at the site of the stenosis, we ballooned with a focused balloon. We performed balloon angioplasty with a 6.0 mm x 150 mm Lutonix (Bard PV) and a 6.0 mm x 120 mm Stellarex balloon (Philips), and after removing the balloons and confirming patency (Figure 7, VIdeo 7), we performed closure of the antegrade access site with a Mynx device (Cardinal Health). The fluoroscopy time was 17.3 minutes.
The performance of complex peripheral intervention requires knowledge of anatomy, the skills to perform multiple access approaches, and the ability to recognize when to utilize these different approaches. With the long Terumo sheaths, we now routinely treat iliac and proximal SFA disease via the radial approach, reducing the patient’s stay at the hospital as well as eliminating potential groin complications. When treating long SFA occlusions in the distal third of the vessel, operators in general attempt to avoid stenting, particularly when the lesion is close to the femoral bone or the joint space. A centering device such as the CrossLock theoretically will facilitate maintenance of endoluminal position while minimizing the risk of dissection. With the use of coronary support catheters, we have found small .014-inch wires to be less likely to cause an extensive dissection. Studies suggest that the performance of atherectomy coupled with a drug-eluting balloon may improve success over the use of atherectomy with simple balloon angioplasty.3 We have experienced fewer dissections when using atherectomy coupled with a focused balloon and a drug-eluting balloon.
One of the problems in treating complex coronary and peripheral intervention is the use of a complicated approach to a simple problem. The original goal of the Prodigy catheter, which evolved into the CrossLock, was to simplify the antegrade approach for the average interventionist attempting to cross coronary as well as peripheral CTOs.4 In peripheral interventions, the CrossLock is a support catheter that can be utilized to allow placement of balloons, lasers, and stents without support catheter removal5 (as noted, for orbital atherectomy, removal in this case was required). If new technology is very complicated to use, that does not help the interventionist. In our case, the interventional fellow performed the entire procedure, and reported that the CrossLock device appeared to be simple, safe, and intuitively obvious. We look forward to the further experience of other operators with this device, which we feel will improve not only procedural success, but perhaps offer a reduction in procedure time as well as utilization of equipment in performing complex peripheral and coronary interventions.
- Lichaa H, Santucci C. Guide catheter extension for complex coronary interventions: a necessary double-edged sword. Cath Lab Digest. 2018 July;26(7). Available online at https://www.cathlabdigest.com/article/Guide-Catheter-Extension-Complex-Percutaneous-Coronary-Interventions-Necessary-Double-Edged. Accessed October 19, 2018.
- Moualla S, Khan S, Heuser RR. Anchoring improved: introduction of a new over-the-wire support balloon. J Invasive Cardiol. 2014 Sep; 26(9): E130-E132.
- Zeller T, Langhoff R, Rocha-Singh KJ, et al; DEFINITIVE AR investigators. Directional atherectomy followed by a paclitaxel-coated balloon to inhibit restenosis and maintain vessel patency: twelve-month results of the DEFINITIVE AR study. Circ Cardiovasc Interv. 2017 Sep; 10(9). pii: e004848. doi: 10.1161/CIRCINTERVENTIONS.116.004848.
- Heuser RR, Murarka S. Chronic total occlusions: successful recanalization of very old lesions. Catheter Cardiovasc Interv. 2013; 81: 802-809.
- Heuser RR, Zang K, Mollen AJ. A step forward: The use of the CrossLock catheter in a patient with critical limb ischemia and a popliteal occlusion. J Invasive Cardiol. 2016; (28): E13-16.
Disclosure: Dr. Heuser reports he is a co-developer of the CrossLock Catheter. Dr. Nachiket reports no conflicts of interest regarding the content herein.
The authors can be contacted via Dr. Richard Heuser at email@example.com.