A successful retrograde re‐entry at aorta using the outback LTD catheter for a bilateral common iliac artery occlusion

The Outback LTD re‐entry catheter system has become a valuable tool for peripheral intervention and it has been widely used for variable peripheral chronic total occlusion (CTO). However, its use in the setting of the aorta was restricted because of concerns of bleeding risks resulting from re‐entry puncture or ballooning. This report presents a case of successful re‐entry using the Outback LTD Re‐Entry Catheter (Cordis, Bridgewater, New Jersy) at the aorta in a patient with bilateral common iliac artery occlusion. © 2013 Wiley Periodicals, Inc.     

Endovascular revascularization of a surgically ligated superficial femoral artery: A case report

We present a case of a patient with left lower extremity ischemic rest pain who initially underwent surgical profundaplasty requiring ligation of his superficial femoral artery (SFA). The patient developed continued rest pain due to diffuse disease of his profunda and inadequate collaterals. Endovascular intervention was therefore performed to the oversewn SFA. Retrograde left SFA access was obtained and the origin of the SFA was recanalized with true lumen re‐entry using an ultrasound guided re‐entry catheter. Angioplasty was performed at the origin of the SFA and self‐expanding stents were deployed in the proximal and mid left SFA. Hemostasis at the distal left SFA access site was obtained by balloon inflation at the access site and manual compression. This case illustrates the feasibility of endovascular repair of a ligated SFA. © 2015 Wiley Periodicals, Inc.     

Initial experience with a dedicated coronary re-entry device for revascularization of chronic total occlusions

Objective : The aim of this registry was to evaluate a new device designed to facilitate antegrade guidewire re‐entry into the true lumen of a chronic total coronary occlusion (CTO) from the adjacent subintimal space. Background : Successful recanalization of CTOs results in clinical improvement in appropriately selected patients. CTO intervention is time‐ and resource‐consuming, and a simplified approach enabling antegrade guidewire re‐entry into the distal true lumen might improve success. Methods : Patients with CTO and ischemia were entered into a prospective registry regardless of lesion characteristics. If wire manipulation resulted in subintimal wire entrapment, a new re‐entry tool (a 2.5‐mm flat subintimal balloon with two exit ports offset by 180°) was used as a platform to attempt guidewire penetration into the distal true lumen. The primary endpoint assessed was successful device‐guided re‐entry. Standard techniques were then utilized to open the CTO. Results : In 40 consecutive CTO lesions attempted, 19 resulted in subintimal wire entrapment (mean occlusion length 44 mm). Sixteen of these 19 were successfully crossed with an antegrade guidewire into the distal true lumen using the new device (84%). One patient with unsuccessful re‐entry was subsequently recanalized with a retrograde technique. All crossed lesions were stented (17/17), resulting in TIMI 3 flow without major complications. Two cases were unsuccessful. One patient had a grade I coronary perforation requiring no treatment. Conclusions : A new device to recanalize CTOs complicated by subintimal wire entrapment can be used successfully by experienced operators. Further study of this coronary re‐entry device is ongoing. © 2011 Wiley Periodicals, Inc.     

Recanalization of chronic occlusions of the superficial femoral artery using the outback™ re‐entry catheter: A single centre experience

Purpose : To report our experience with a catheter system (The Outback? catheter) designed to allow fluoroscopically controlled re‐entry after subintimal guide wire passage during recanalization of chronically occluded femoro‐popliteal arteries. Methods : Between March 2007 and August 2008, 65 legs in 61 patients (60% male, mean age 73 (49–98 years) with chronic occlusion of the SFA and proximal popliteal artery were treated. Clinical presentation was severe intermittent claudication (Rutherford category 3, 59%), rest pain (Rutherford category 4, 16%), and minor ulcerations (Rutherford category 5, 25%). In all cases, the true lumen could not be entered by using standard antegrade catheter and guide wire techniques. Results : Median lesion length was 200 ± 102 mm. Recanalization of the arterial occlusion was successful in 57 of 65 treated lesions (88%). One patient died of myocardial infarction after delayed femoral bleeding possibly due to extensive recanalization attempts. There were no further procedure‐related complications. Conclusion : Use of the Outback? re‐entry catheter system is a valuable option for interventional therapy of chronically occluded femoro‐popliteal arteries following failed standard antegrade recanalization attempt. © 2009 Wiley‐Liss, Inc.     

The “double stingray technique” for recanalizing chronic total occlusions with bifurcation at the distal cap

Antegrade dissection re‐entry is often discouraged for chronic total occlusions (CTOs) with a bifurcation at the distal cap due to risk of side branch occlusion that can lead to periprocedural myocardial infarction and incomplete revascularization. Antegrade dissection re‐entry, however, is often needed, especially in complex cases. We present the novel “double Stingray technique” for CTOs involving bifurcations, in which the Stingray system is used twice for re‐entry into both vessel branches, followed by two‐stent bifurcation stenting to maintain the patency of both branches.     

Intravascular ultrasound guided wiring re‐entry technique for complex chronic total occlusions

Background

The successful recanalization rate of chronic total occlusion (CTO) lesions without retrograde collaterals available is always low. Intravascular ultrasound (IVUS) may be useful to guide the subintimal guidewire to re‐enter the true lumen. We evaluated the clinical feasibility and efficacy of the IVUS‐guided wiring re‐entry technique for these complex CTO lesions.

Methods

Twenty consecutive patients (19 male, mean age: 65.3 ± 12.8 years) with both failed antegrade and retrograde approaches were enrolled. The IVUS catheter was introduced into the subintimal space to identify the entry point into the subintimal space, and guide another stiff wire to re‐enter the true lumen with the adjacent side‐branch or first wire as markers, or using IVUS‐guided parallel wire technique.

Results

The entry point into the subintimal space was identified by IVUS in all cases, and the IVUS‐guided wiring re‐entry technique succeeded in 17 cases (85%). No procedure‐related complication was noted except one case of delayed cardiac tamponade due to the wire perforation. During the mean follow‐up period of 1.9 ± 1.3 years, there was no adverse cardiac event, except one patient died of the complication of cardiac transplantation.

Conclusion

The IVUS‐guided wiringre‐entry technique might be feasible and safe for the recanalization of complex CTO lesions.

     

Entrainment mapping: Theoretical considerations and practical implementation

Entrainment mapping enables the diagnosis and characterization of reentrant arrhythmias from analysis of the specific interaction between pacing maneuvers and tachycardia. Described 40 years ago, the implementation and interpretation of pacing maneuvers to entrain tachycardias has evolved into an indispensible tool for diagnosis and mapping reentrant cardiac arrhythmias. For complex re‐entry pathways entrainment mapping allows determination of the relation of pacing sites to the re‐entry circuit and discrimination of relevant re‐entry parts from bystander areas. Careful interpretation is needed to recognize misleading findings. The general physiology of re‐entry, and the application, interpretation, limitations, and pitfalls of entrainment maneuvers used for cardiac mapping is reviewed.     

Intravascular ultrasound optimization of drug‐eluting stents: Still not enough data

One of the mechanisms of technical failure in the treatment of tibial artery occlusive disease includes an inability to re‐enter the true lumen of the tibial vessel distal to the occlusion following tracking of the interventional wire into the subintimal space. We report the first case using a coronary 0.014″ re‐entry system (Stingray? Chronic Total Occlusions Re‐entry System, BridgePoint Medical) in the treatment of a complex tibial artery occlusion where the antegrade approach initially failed due to this mechanism. The re‐entry system allowed completion of antegrade recanalization of the occlusion and represents an important addition to the interventional armamentarium for the treatment of complex tibial artery disease. © 2010 Wiley‐Liss, Inc.     

One‐year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re‐entry techniques

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re‐entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer‐term outcomes are unknown, particularly in relation to dissection and re‐entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid‐trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One‐year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2–4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re‐entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re‐entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re‐entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire‐based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one‐year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.     

Percutaneous endoluminal anatomical bypass for patients with external iliac artery occlusion after failed conventional endovascular recanalization

Endovascular therapy, an established first‐line treatment for isolated iliac artery (IA) occlusion (IAO), may be of limited use in challenging lesions. We describe a novel percutaneous endoluminal anatomical bypass (PEApass) technique for uncrossable external IA (EIA) occlusion. A 70‐year‐old man on hemodialysis with a history of colostomy presented with chronic limb‐threatening ischemia due to a left EIA with below‐the‐knee occlusions. During a previous colostomy, the left EIA was accidentally ligated. Conventional endovascular recanalization for the ligated EIA failed, and a femoral‐femoral bypass and below‐knee angioplasty were performed as alternative therapy. Two weeks later, surgical site infection developed at both anastomosis sites. PEApass was performed prior to removing the infected graft. An arteriovenous fistula (AVF) in the distal location was created using a re‐entry device, and its proximal location was created using a 0.014‐in. penetration guidewire, which was snared on the inside of the iliac vein (IV) using a retrograde snare. The proximal and distal sections of the IA were connected using an 8.0‐mm × 100‐mm stent graft implanted through the IV. A final angiogram indicated that flow to the occluded IA was completely restored without complications. Following the PEApass, the infected graft was removed. Complete wound healing was achieved within approximately 1 month. This innovative PEApass procedure is feasible and could be an alternative procedure for patients with uncrossable IAO.     

Pulmonary vein triggers,focal sources,rotors and atrial cardiomyopathy: implications for the choice of the most effective ablation therapy

Understanding of the pathophysiological mechanism(s) underlying atrial fibrillation (AF) is the foundation on which current ablation strategies are built. In the vast majority of patients with paroxysmal AF, the ablation procedure should target the pulmonary veins. In patients with nonparoxysmal AF, however, pulmonary vein isolation alone seems to be insufficient to prevent the arrhythmia. Several recent clinical trials have investigated the concept that rotors (re‐entry based on a meandering central core from which spiral waves emanate) might be the mechanism responsible for sustaining AF. Ablation of these localized AF sources is an important step towards substrate‐driven procedures in persistent AF. Hybrid AF ablation procedures, based on the integration of endocardial transcatheter and epicardial off‐pump surgical techniques, have been introduced to overcome their mutual shortcomings. The long‐term results are encouraging, especially in currently challenging settings such as nonparoxysmal AF and failed endocardial catheter ablation procedures.     

Does the end justify the means? The contemporary role of dissection/re‐entry strategies for recanalization of coronary chronic total occlusions

• Antegrade and retrograde dissection/re‐entry techniques are frequently utilized in contemporary CTO PCI, especially for complex lesions.
• One‐year outcomes with modern dissection/re‐entry techniques appear favorable and comparable with those achieved after intraplaque crossing, supporting their increased use.
• Randomized data on the procedural safety, efficiency, and long‐term outcomes of subadventitial CTO PCI techniques are needed.

     

Succesful antegrade subintimal bypass restenting of in‐stent chronic total occlusion

Coronary chronic total occlusions (CTOs) are known to cause significant patient morbidity. Over the past several years, the techniques and devices for treating these CTOs have advanced tremendously. The interventional management of CTOs within previously placed coronary stents, however, remains challenging. Here, we present a case of an in‐stent restenosis of the right coronary artery CTO bypassed using a controlled subintimal dissection re‐entry technique via antegrade approach creating side‐by‐side stents. © 2015 Wiley Periodicals, Inc.     

Contrast modulation in chronic total occlusion percutaneous coronary intervention

The intraplaque injection of contrast media in the recanalization of coronary chronic total occlusions (CTO) has witnessed a dynamic journey since its initial formulation. Contrast‐guided subintimal tracking and re‐entry (STAR) was the first contrast modulation technique for CTO percutaneous coronary intervention (PCI). With this technique, a forceful injection of a large volume of contrast (3–4 mL) was performed in order to achieve hydraulic recanalization of the vessel. This approach was associated with extensive vessel injury and unpredictable true lumen re‐entry, which were in turn linked to high rates of restenosis on follow‐up. In the subsequent iteration, called the “microchannel technique”, a smaller amount of contrast media (1 mL) was gently injected inside the plaque to modify its compliance by softening and recruiting loose tissue, which facilitated subsequent true‐to‐true lumen crossing with a polymer‐jacketed wire along paths of least resistance. The microchannel technique has later evolved into what is currently known as the “Carlino technique”, where a minimal volume of contrast media (<0.5 mL) is gently injected inside the occlusion, with the goal of modifying plaque compliance to facilitate guidewire and microcatheter advancement through a fibrocalcific plaque. The Carlino technique is now widely utilized to allow negotiation of difficult‐to‐cross occlusions, particularly by the “hybrid operators”, with high success rates and low incidence of complications. The purpose of this article is to provide a historical perspective on the use of contrast modulation in CTO PCI, its pathophysiological basis, as well as technical recommendations on how and when to perform these maneuvers.     

Recurrent coronary artery thrombosis after anomalous right coronary artery re‐implantation to the aorta

Anomalous origin of the right coronary artery (RCA) from the pulmonary artery is a rare entity. The current recommendation is corrective operation even in asymptomatic patients when this cardiac malformation is found. We report a case of a 21‐year‐old male who initially presented with ST elevations. After surgical repair with re‐implantation of the RCA to the aorta, he was found to have an acute thrombus in his left circumflex and several months later developed a thrombus in the proximal left anterior descending artery. We propose that the change from a hyperkinetic high flow state to a slow flow state in the setting of inadequate coronary flow reserve and endothelial function predisposed our patient to thrombus formation in the persistently dilated coronary arteries. It is expected that restoration of normal flow pattern in all coronary arteries will result in normalization of perfusion, decrease in feeding artery size, and return of endothelial function. Because this anomaly is rare, limited information exists on the effects of the procedure on myocardial perfusion. These findings raise the question of whether re‐implantation of the anomalous artery is truly the superior approach. © 2013 Wiley Periodicals, Inc.     

Management of anomalous circumflex coronary artery from the neo‐pulmonary artery in an adolescent following neonatal arterial switch operation

A 15‐year‐old male with transposition of the great arteries presented with exertional chest pain. He was found to have a circumflex coronary artery from the neo‐pulmonary artery that had not been transferred during his arterial switch operation. The circumflex coronary artery, fed through collaterals from a re‐implanted single coronary artery, resulted in coronary steal. This report describes a management pathway to treat this rare anomaly. © 2014 Wiley Periodicals, Inc.     

“Move the cap” technique for ambiguous or impenetrable proximal cap of coronary total occlusion

Antegrade crossing remains the most commonly employed crossing strategy for coronary chronic total occlusions (CTOs) but can be challenging to perform in cases of ambiguous or impenetrable proximal cap. To successfully treat such cases, we describe a technique named “move the cap,” in which the subintimal space is entered proximal to the proximal cap using a stiff coronary guidewire or facilitated by inflating a slightly oversized balloon. Subintimal guidewire entry is followed by standard antegrade dissection and re‐entry. The “move the cap” technique can facilitate crossing of CTOs with ambiguous or impenetrable cap, while minimizing the risk of perforation. This technique is also useful for treating balloon uncrossable lesions. © 2015 Wiley Periodicals, Inc.     

Intravascular ultrasound‐guided retrograde wiring for chronic total occlusion

This report describes a retrograde wiring technique, using intravascular ultrasound, for a blunt chronic total occlusion with a side branch at the site of occlusion of which the operator has difficulty of awareness of the proper re‐entry point with the retrograde wire angiographically. © 2009 Wiley‐Liss, Inc.     

Progress in the retrograde approach for chronic total coronary artery occlusion

After the introduction of the retrograde approach in percutaneous coronary intervention for chronic total occlusion (CTO), different kinds of strategies and techniques have been developed in order to achieve final success. However, it has not been fully demonstrated whether these strategies and techniques can really improve the final result. We observed one case, for which the initial attempt of the retrograde approach for a CTO lesion was unsuccessful despite the successful approach of a retrograde guidewire to the lesion, and with the second retrograde approach 3 years later being eventually successful by using various kinds of strategies and techniques. This case clearly demonstrates how the final success through the retrograde approach can be achieved by using a combination of the improved strategies and techniques for CTO lesions. © 2008 Wiley‐Liss, Inc.     

Transcatheter treatment for systemic‐to‐pulmonary artery shunt obstruction in infants and children

Systemic‐to‐pulmonary artery shunt occlusion is a life‐threatening complication in patients with shunt‐dependent pulmonary blood flow. In the current era, the definitive diagnosis of shunt obstruction, and interventions to re‐establish shunt patency are performed in the catheterization laboratory, rather than the operating room. This review summarizes the various transcatheter techniques used by the interventionalist to re‐establish flow through occluded shunts. © 2008 Wiley‐Liss, Inc.