Retrograde parallel wire technique using a dual lumen catheter can be useful for percutaneous coronary intervention with chronic total occlusion

Abstract

The patient was a 61-year-old male with chronic total occlusion (CTO) of the right coronary artery (RCA). We performed percutaneous coronary intervention (PCI) to RCA-CTO with the bidirectional approach via the left anterior descending artery. In retrograde approach, the first wire entered the false lumen at the segment of severe stenosis of the CTO distal site. We performed parallel wire technique using a dual lumen catheter to avoid branch loss and succeeded to get the proximal true lumen through the second wire. When the first wire enters the false lumen, continued advancement of this wire easily should be avoided as it can collapse the true lumen and make reentry difficult. On top of that, in retrograde approach, it is difficult to perform parallel wire technique without using a dual lumen catheter. This case reveals that retrograde parallel wire technique using a dual lumen catheter is an extremely effective strategy to treat CTO.

<Learning objective: The dual lumen catheter is one of the most helpful devices. However, in the field of percutaneous coronary intervention for chronic total occlusion (CTO-PCI), especially retrograde approach, the usage of them has not been established. Retrograde parallel wire technique using a dual lumen catheter may be useful for CTO-PCI.>

Introduction

Percutaneous coronary intervention for chronic total occlusion (CTO-PCI) remains one of the most challenging areas in interventional cardiology. New devices (guidewires, micro-catheters) and extraordinary technical advancement have increased the success rate of CTO-PCI [1], [2], [3], [4]. Above all, the development of the dual lumen catheter and establishment of new usage was innovative. At first, the dual lumen catheter was designed with the express purpose of managing bifurcation lesions [5], [6]. Nowadays, it has been used not only for bifurcation lesions but also CTO lesions. But, there are few reports about the usage of a dual lumen catheter in the CTO-PCI. Here, we report the case of a CTO-PCI that was successfully treated with retrograde parallel wire technique using a dual lumen catheter.

Case report

A 61-year-old male was diagnosed with unstable angina pectoris (UAP) at another hospital several months previously. Emergent coronary angiography (CAG) showed the right coronary artery (RCA) had totally occluded and the left coronary artery (LCA) had a severe stenotic lesion in the proximal left circumflex artery (LCX) and left anterior descending artery (LAD). The causative lesion of UAP was judged as LCX, and two zotarolimus-eluting stents (ZES) were implanted there at the same time. One month later, another ZES was implanted in the LAD. And then he was referred to our hospital for PCI to RCA-CTO.

CAG at the previous hospital revealed the RCA was totally occluded at the ostium just after branching of the conus. We could detect the peripheral filling through the right superior septal perforator (RSSP) artery to right ventricular (RV) branch (Fig. 1A). LAD had collateral artery from the apex to the distal posterior descending artery (PD). Collaterals from the septal branch were undetectable actually (Fig. 1B).

Fig. 1.

CAG at previous hospital. (A) RCA was totally occluded at the ostium after branching the conus. White arrow heads indicate CTO lesion. White arrows indicate RSSP. (B) LAD had collateral artery from the apex to the distal PD (White arrow head). Collaterals from the septal branch were undetectable actually.

CAG, coronary angiography; RCA, right coronary artery; CTO, chronic total occlusion; RSSP, right superior septal perforator; LAD, left anterior descending artery; PD, posterior descending artery.

PCI was performed with bilateral femoral approach. An 8Fr Launcher JR4.0 SH guiding catheter (Medtronic Inc., Fridley, MN, USA) was inserted into the RCA, and an 8Fr Launcher EBU3.5 SH guiding catheter was inserted into the LCA. We performed simultaneous left and right CAG (Fig. 2A). However, the exit of CTO was unclear exactly. Initially, we tried antegrade approach, but could not deliver the intravascular ultrasound (IVUS) catheter and balloon catheter toward the conus branch. Therefore, we switched to retrograde approach. A SION guidewire (Asahi Intecc Co., Ltd., Aichi, Japan) with a Corsair micro-catheter (Asahi Intec) was introduced into the septal branch. Selective tip injection through the Corsair revealed a misty connection toward PD. A XT-R guidewire (Asahi Intecc) with the Corsair was successfully introduced into PD, and the Corsair was advanced into the PD. Tip injection through the Corsair from PD was performed, which confirmed that the exit of the CTO was a branching part of the RV and the distal part of CTO had a severe stenotic lesion (Fig. 2B). And then the guidewire was exchanged for the SION and advanced into the distal severe stenotic lesion. But, the SION entered the false lumen (Fig. 2C). So, we tried to perform the parallel wire technique [7] using a SASUKE dual lumen catheter (Asahi Intecc). The Corsair was exchanged for the SASUKE. It could be passed through the septal channel easily. The SION was left in place, and a SION black guidewire (Asahi Intecc) was passed parallel to the SION aiming for the proximal true lumen (Fig. 2D). The SION black was successfully introduced into the acute marginal branch (Fig. 2E). The SASUKE was exchanged for the Corsair again. It was passed through the distal severe stenotic lesion. The SION black was exchanged for the ULTIMATE bros3 guidewire (Asahi Intecc) and advanced retrograde into the CTO. Because the retrograde wire was not advanced into the proximal true lumen, a Gaia Next 2 guidewire (Asahi Intecc) with the Corsair was advanced antegrade toward the retrograde guidewire. And then reverse controlled antegrade and retrograde subintimal tracking (CART) technique [8] was performed with a 3.0 × 15 mm LAXA balloon (Goodman Co., Ltd., Aichi, Japan) (Fig. 2F). Finally, The SION black was successfully introduced into the proximal true lumen. The retrograde wire was advanced into the antegrade guiding catheter with the Corsair and exchanged for a 330 cm RG3 guidewire (Asahi Intecc). Wire externalization was then completely achieved.

Fig. 2.

Imaging findings during PCI. (A) Simultaneous left and right coronary angiography. The exit of CTO was unclear exactly. The white arrow heads indicate RV branch. (B) Tip injection through the Corsair from PD. White arrow heads indicate severe stenotic lesion. The white arrow indicate the exit of CTO. (C) Retrograde wire entered the false lumen (white arrow). (D) Retrograde parallel wire technique using dual lumen catheter. The white arrow head indicates dual lumen catheter. (E) Second wire was successfully introduced into acute marginal branch (white arrow heads). (F) Reverse-CART was performed.

PCI, percutaneous coronary intervention; CTO, chronic total occlusion; RV, right ventricular; PD, posterior descending artery; CART, controlled antegrade and retrograde subintimal tracking.

Subsequently, the SION blue guide wire was introduced antegrade into the atrio-ventricular branch (AV) with the SASUKE. After pre-dilation, 4 biodegrable polymer-everolimus-eluting stents (SYNERGY) (3.0 × 24 mm, 3.0 × 28 mm, 2.75 × 38 mm, 2.5 × 38 mm) (Boston Scientific Inc., Natick, MA, USA) were deployed from the proximal to the distal RCA. Final coronary angiography revealed a good result (Fig. 3).

Fig. 3.

CAG after the PCI.

CAG, coronary angiography; PCI, percutaneous coronary intervention.

Discussion

Because of modern-era improvements in PCI techniques and devices, the technical and procedural success rates and long-term outcomes of CTO-PCI have significantly improved [1], [2]. The introduction of the retrograde approach, especially the reverse CART technique, has contributed to the improved success rate of wire crossing [3], [4]. In the PCI devices, one of the most useful devices was the dual lumen catheter. Dual lumen catheters are the type of micro-catheter that have both monorail lumen and over the wire (OTW) lumen. They allow the operator to deliver a second wire through the OTW lumen while leaving the guidewire in the monorail lumen in place. The new dual lumen catheter SASUKE was introduced, so now two products are available, including a Crusade (KANEKA MEDIX CORP., Osaka, Japan). These catheters were originally created for the treatment of stenosis close to the bifurcations, when the guidewire does not provide the right support to engage the side branch [5], [6]. In addition, when the guidewire is reintroduced into LCX through the stent strut after stenting to left main trunk (LMT), we often use these catheters. These are common usage, but recently, they have been used in various situations in the CTO-PCI. There are few literature reports on usage of them. The major usages are as follows: (i) the first wire is introduced antegrade into the side branch in the monorail lumen, and we aim at the proximal cap of the CTO with the second wire in the OTW lumen. (ii) When the first wire enters the false lumen, it is left in place, and the second wire (typically stiffer and tapered with different tip bend) [7] in the OTW lumen is passed along the same path parallel to the first wire (parallel wire technique using a dual lumen catheter). (iii) When there is a highly angulated side branch of CTO exit, we can perform reverse wire technique using dual lumen catheter [5], [6], [9]. As for each usage mentioned above, using a dual lumen catheter makes strong backup and improves the operability of the guidewire. The first wire in the monorail lumen can fix and stabilize the micro-catheter, so the movement of the micro-catheter due to heart beat can be controlled.

In this case, because the first wire entered the false lumen in retrograde approach, we performed parallel wire technique using a dual lumen catheter (SASUKE) and succeeded to get the proximal true lumen through the second wire. Generally, when the first wire enters the false lumen, continued advancement of this wire easily should be avoided as it can collapse the true lumen and make reentry difficult. In the case of retrograde approach, it is difficult to perform parallel wire technique without using a dual lumen catheter. In addition, backup and operability of the wire is inferior as compared with antegrade approach, the dual lumen catheter is extremely useful for retrograde approach. Recently, tracking and passage performance of the dual lumen catheter has been improved. If the micro-catheter was passed through collateral channel, dual lumen catheter often can be passed, too (Dotter effect [10]). Finally, we summarize the tips of retrograde parallel wire technique in our hospital. (i) Micro catheter: the Corsair is regarded as the first choice due to superior pushability, kinking resistance, and channel dilator. (ii) Dual lumen catheter: formerly, we sometimes used the Crusade with retrograde parallel wire technique, however recently the SASUKE is regarded as first choice for good tracking and passage performance. (iii) Collateral channel: basically, we use the septal channels, mainly due to safety issue [8]. But if there are less tortuous and large diameter channels, it may be possible even with epicardial channels. (iv) Complications: complications of retrograde parallel wire technique are similar to usual retrograde approach. For example, collateral channel dissection, perforation, hematoma, and catheter entrapment [8].

This is the first report of retrograde parallel wire technique using the dual lumen catheter. In the field of CTO-PCI, it will lead to an increase of the initial success rate to use the dual lumen catheter appropriately.

Conclusion

We successfully performed retrograde parallel wire technique using a dual lumen catheter. It can be one of the useful options for CTO-PCI.

Conflict of interest

The authors declare that there is no conflict of interest.