A 62-year-old male with a history of coronary artery bypass graft surgery and who is an active smoker presented with Canadian Cardiovascular Society (CCS) class 3 angina and New York Heart Association (NYHA) class 3 congestive heart failure (CHF). He agreed to elective chronic total occlusion (CTO) right coronary artery (RCA) percutaneous coronary intervention (PCI). A nuclear SPECT regadenoson stress test showed inferior reversible perfusion defect. Bilateral transradial access was used for dual injection angiography. Angiography showed:
- A saphenous vein graft (SVG) to RCA with a distal saphenous vein graft (SVG) 90% lesion and an occluded posterior descending artery (PDA) past the graft (Figure 1, Video 1);
- Patent left interior mammary artery to the left anterior descending artery (LIMA to LAD);
- Patent Y graft to diagonal and obtuse marginal (OM).
The RCA had a proximal diffuse 80% stenosis and mid CTO (Figure 2, Video 2). Dual injections demonstrated a short lesion with a blunt cap on both sides. We began with the antegrade wire escalation technique. However, it failed as the Pilot 200 (Abbott Vascular) wire went subintimal right at the lesion distal cap. Antegrade dissection reentry was not performed. We transitioned to retrograde approach using the SVG to RCA as our conduit. Using a Pilot 200, Corsair (Asahi Intecc) 150 cm microcatheter, a 6 French (Fr) GuideLiner (Teleflex) guide extension, and a 6 Fr Amplatz 0.75 guide catheter, we were able to penetrate the distal CTO cap (Figure 3, Video 3). The wire went from the retrograde true lumen into the antegrade true lumen. While the retrograde wire crossed the CTO, the Corsair catheter would not advance behind it. In order to form a supportive rail with the retrograde wire, we wanted to perform balloon trapping of the wire in the Judkins right (JR) 4 antegrade guide catheter. First, the retrograde wire had to be inserted into the antegrade guide. The Pilot 200 could not be directed into the guide catheter at the ostium. Therefore, the GuideLiner was advanced past the ostium into the stenotic proximal RCA, occluding the lumen. The Pilot 200 wire was advanced into the GuideLiner lumen and up the guide (Figure 4, Video 4). The Corsair catheter successfully crossed the lesion retrograde, using the trapped Pilot as a support rail. The Corsair created a channel inside the lesion that was large enough for an antegrade wire and small balloon to fit through. The Corsair was slowly retracted using a back-and-forth technique while an antegrade Balance Middleweight (BMW) wire (Abbott Vascular) was simultaneously advanced immediately behind it. The wire was able to follow or “chase” the Corsair tip as it moved through the lesion into the distal true lumen (Figure 5, Video 5). The retrograde wire and micro catheter were removed so balloon angioplasty and stenting could take place. The final result was complete resolution of the CTO (Figure 6, Video 6).
Retrograde wire externalization provides excellent support for ballooning and stenting CTO lesions. However, when using the externalization technique, tension will develop in the collateral system, which can result in collateral shearing, rupture, or, even worse, slicing of the heart. The traditional method of wire externalization can be high risk. Our antegrade wire technique is safe, effective, and a valid alternative to reduce risk to the patient and achieve a successful result.
Bilateral transradial access was chosen due to its patient safety advantages over femoral access. No compromises needed to be made due to 6 Fr guides from the radial approach. We began with antegrade wiring and when that was unsuccessful, changed strategy to retrograde true lumen puncture instead of antegrade dissection and reentry. A GuideLiner was used to occlude the antegrade lumen and capture the retrograde wire, because the wire would not steer into the guide. Wire trapping was performed to improve support, because the Corsair would not cross the lesion over the wire. We again attempted to cross antegrade. The Corsair was withdrawn in a back-and-forth motion, with the antegrade BMW wire following its lead. This technique was also used to minimize the risk of subintimal wire dissection, especially since an antegrade wire dissection occurred in the first stage of the case. The Corsair left a small channel at its tip, in which the antegrade wire was able to fit and cross the CTO. We named this technique “bamboleo”, which in Spanish means “I sway”. The bamboleo technique is a novel approach for antegrade wire crossing that was successful in this case and maintained true lumen access.
Disclosure: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Philip Carson, MD, at firstname.lastname@example.org.