A new understanding of chronic total occlusion from a novel PCI technique that involves a retrograde approach to the right coronary artery via a septal branch and passing of the guidewire to a guiding catheter on the other side of the lesion.

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) by the antegrade approach is sometimes difficult, especially in the right coronary artery (RCA). We performed successful PCls following a retrograde approach via a septal branch in 2 patients with CTO in RCA. The method involves leading the retrograde guidewire outside the body through an opposite guiding catheter after the wire crosses the target lesion. A balloon or stent could then be delivered retrogradely or antegradely. Even a soft retrograde wire always crosses the lesion through the true lumen, as confirmed by IVUS. Selecting a suitable collateral, a straighter rather than a larger one, is crucial. Our results do not support the current concept regarding CTOs. Probably, the distal fibrous cap is soft and the proximal one has a thin point that soft wires, even blunt ones, can penetrate easily. The distal penetration point appears to connect to the proximal uncalcified thin point. Many channels seem to spread out from the proximal side, tree-like, within the lesion. In the retrograde approach, the wire is unlikely to enter these branch channels. The results suggest that PCI by the retrograde approach may be effective for treating CTOs of RCA.     

Utilization of a double-wire technique to treat long extended spiral dissection of the right coronary artery. Evaluation of incidence and mechanisms

While coronary artery dissection caused by a guiding catheter, which is one of the most commonly occurring complications during diagnostic cardiac catheterization or coronary intervention, has various forms, extensive antegrade and retrograde dissections of the right coronary artery (RCA) are rarely observed during these procedures. Within the last three years, we retrospectively reviewed our experience with 12,600 consecutive patients who underwent either diagnostic cardiac catheterization or coronary angioplasty, and found that 17 (0.14%) of the patients displayed extensive antegrade and retrograde RCA dissection. The antegrade dissection always propagated to the distal RCA either on bifurcation of the posterior descending artery and posterolateral artery (PLA) or to the proximal PLA. The retrograde dissection was always observed close to the ostium of the RCA or extending to the ostium of the RCA. TIMI-0 flow in the RCA was immediately observed in all the patients. Chest pain associated with an electrocardiogram showing ST-segment elevation was soon observed in most of the patients. The true lumen could be entered successfully using a single wire in 8 of 17 patients. However, a double-wire technique was required for 7 patients. This technique involved first advancing a wire along to the false lumen and then pulling back the guiding catheter away from the ostium of the RCA for a few millimeters followed by anchoring with the wire. Another wire was then gently inserted into the true lumen from the dissection entrance point, which was located near or at the ostium of RCA, and carefully advanced to the distal RCA. Coronary stenting was successfully deployed in 15 patients. However, the procedure failed in 2 patients. Furthermore, this complication caused 7 patients to have acute myocardial infarctions, 2 patients to develop atrial fibrillation, and I to die from ischemic enterocolitis due to cardiac embolism after 7 months of follow-up. In conclusion, with an increase in experience, we now better understand this complication. However, this complication, which is a formidable challenge for coronary intervention, may be a life-threatening complication, and patients with this complication may face the potential risk of a nonfatal myocardial infarction, or even a long-term fatal outcome in the long-term. Accordingly, it is important to learn how to promptly manage this complication.     

Rescue of trapped Rotablator with knuckle technique for chronic total occlusion

A 71-year-old man with Chagas disease and stable angina on minimum exertion underwent coronary computed tomography angiography and cine angiography that revealed heavily calcified multivessel disease involving the left main artery (LM). Due to the degree of calcification, it was decided to perform rotablation. The first-stage percutaneous coronary intervention (PCI) with rotablation was performed on the LM, left anterior descending artery and second diagonal branch without complications. Almost 30 days later he returned for right coronary artery (RCA) PCI. The proposed strategy was rotational atherectomy in the posterior descending artery (PDA) and right posterolateral artery (RPLA) with a 1.5 mm burr, followed by implantation of two drug-eluting stents (DES). Through right femoral artery access the RPLA lesion was ablated with success. As there were no signs of dissection and TIMI 3 flow was maintained, the 0.009″ RotaWire was repositioned to cross the PDA lesion and debulking of the lesion was performed. After two attempts we succeeded in crossing the lesion with the 1.5 mm burr, however entrapment of the burr ensued. The system was pulled back until the guiding catheter penetrated deep into the RCA, and attempts were made to release the Rotablator by moving it forward and backward, but the burr did not even spin. The contralateral femoral artery was therefore punctured and a 6F JR guiding catheter was inserted, in order to move a guidewire and small angioplasty balloon tangentially to the burr, but without success. Finally we advanced the guidewire using the ‘knuckle’ technique, taking advantage of the kinking of the distal portion of the PT2 guidewire, performing a subintimal dissection and re-entry, and could then easily cross the balloon, inflate it and release the trapped burr. Through the 6F system, two programmed and one bailout DES were successfully implanted in the PDA, RPLA and RCA, obtaining final TIMI 3 flow without complications.     

Treatment of aortocoronary dissection complicating anomalous origin right coronary artery and chronic total intervention with intravascular ultrasound guided stenting

Acute dissection of the ascending aorta is a rare complication of percutaneous coronary intervention (PCI). Its mechanism involves disruption of the coronary intima by mechanical trauma, followed by subintimal injection of contrast, which, in turn, contributes to subsequent extension of the dissection. In contrast to spontaneous aortic dissection of ascending aorta, which mandates immediate surgical intervention, the appropriate therapy and outcome of this rare entity are not well established. We report a case of iatrogenic aortocoronary dissection, complicating transradial PCI for recanalization of anomalous origin right coronary artery (RCA) from the left coronary cusp with chronic total occlusion. The intimal tear was created by a balloon rupture in the proximal RCA, with propagation of dissection into the ostium and the coronary sinus of Valsalva. Intravascular ultrasound (IVUS) guided coronary stenting was performed to seal the entry port, and to break down the dissection route. This case indicates that IVUS can be a useful tool to ensure complete coverage of the intracoronary dissection and precise placement of the stent to fully cover the ostium of the culprit vessel. This can be particularly important in difficult situations, such as anomalous origin of RCA from the left cusp, with acute downward anterior angulation. © 2011 Wiley Periodicals, Inc.     

Intravascular ultrasound-guided creation of re-entry sites to improve intermittent claudication in patients with aortic dissection.

PURPOSE: To report percutaneous fenestration of aortic dissection flaps to relieve distal ischemia using a novel intravascular ultrasound (IVUS)-guided fenestration device. CASE REPORTS: Two men (47 and 62 years of age) with aortic dissection and intermittent claudication had percutaneous ultrasound-guided fenestration performed under local anesthesia. Using an ipsilateral transfemoral approach, the intimal flap was punctured under real-time IVUS guidance using a needle-catheter combination through which a guidewire was placed across the dissection flap into the false lumen. The fenestration was achieved using balloon catheters of increasing diameter introduced over the guidewire. Stenting of the re-entry was performed in 1 patient to equalize pressure across the dissection membrane in both lumens. The procedures were performed successfully and without complications. In both patients, ankle-brachial indexes improved from 0.76 to 1.07 and from 0.8 to 1.1, respectively. Both patients were without claudication at the 3- and 6-month follow-up examination. CONCLUSION: Percutaneous intravascular ultrasound-guided fenestration and stenting at the level of the iliac artery in aortic dissection patients with claudication is a technically feasible and safe procedure and relieves symptoms.     

Diagnostic efficacy of coronary CT angiography as a follow-up modality for procedure-related coronary dissection

Procedure-related coronary dissection is associated with an increased risk of major adverse cardiovascular events after percutaneous coronary intervention (PCI). In most patients with such an iatrogenic complication, further PCI or bypass surgery aimed at complete revascularization is performed. Moreover, conventional coronary angiography has been used as a standard modality in the follow-up of such patients. The present report describes a 70 year old female patient who was complicated by catheter-related extensive coronary dissection in the right coronary artery (RCA) when treated for an acute myocardial infarction. Although RCA flow was insufficient, we decided against revascularization and followed her medically without additional revascularization procedures. Her clinical course had been uneventful for 4 years. However, symptoms of effort angina developed and re-examinations were performed at approximately 5 years after the myocardial infarction. Although conventional coronary angiography failed to show the culprit lesion responsible for the angina symptoms, the superior spatial resolution of the coronary CT angiography clearly identified significant progression of the stenotic lesion in the true lumen of the dissected RCA. Thus, coronary CT angiography might be considered as a possible first-line follow-up modality in patients with procedure-related coronary dissection.     

冠状动脉二支主干堵塞行介入治疗完全血运重建

目的：本研究探讨对16例冠状动脉二支主干堵塞者采用分步和分次冠状动脉介入治疗术（PCI）完全血运重建的有效性和安全性。方法：（1）对5例急性心肌梗死（AMI）,采取一次性分步直接PCI术完成血运重建;（2）对11例不稳定型心绞痛（UAP）,采取多次性分步PCI术达到完全血运重建,首先解除本次发病罪犯血管的堵塞;（3）恰当使用XB导引导管、Crossit硬导丝和Maverick球囊以及主动脉内球囊反搏（IABP）支持。结果：（1）5例AMI二支堵塞冠状动脉均成功植入支架,并首先使左前降支（LAD）再通。（2）11例UAP中21／22支冠状动脉二支主干堵塞处经球囊预扩张后,均成功植入支架,所有堵塞冠脉均获得TIMI-Ⅲ级血流。（3）16例患者术后心电图显示心肌缺血明显改善,心脏超声显示左室射血分数较术前明显改善,由（42±34）％升至（51±44）％。经过平均18个月随访,患者生活质量明显提高,未发生严重心血管事件。结论：冠状动脉二支主干堵塞者行PCI术完全血运重建安全可行;对AMI者优先开通LAD的一次性PCI术安全高效;对慢性堵塞UAP者,优先开通近期罪犯病变的多次性PCI术既可达到完全血运重建,又符合临床实际。     

Transradial retrograde approach rescuing iatrogenic long spiral dissection during chronic total occlusion intervention

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is one of the greatest challenges in coronary interventions. A retrograde approach via the collateral channel has been recently proposed to improve the success rate of PCI in CTO lesions of the coronary arteries. We describe an accidental complication encountered during transradial PCI to recanalize right coronary artery CTO in a patient with unstable angina. A long spiral dissection has been created by antegrade wiring and extended from the ostium all the way down to mid RCA segment. Subsequent attempts with antegrade wiring into the true lumen were unsuccessful. Ad‐hoc retrograde recanalization has been employed to rescue the vessel via septal collateral from left anterior descending artery. Retrograde wiring and dilatation were performed followed by successful antegrade wiring into the true lumen under IVUS guidance, which revealed significant intramural hematoma extending distally to the posterolateral branch. Bailout stenting was achieved with sealing of the multiple entry and exit sites created by the spiral dissection and complete coverage of the intramural hematoma. This report highlights the role of the retrograde approach as a rescue option in the setting of complicated antegrade approach and to improve the success rate of CTO‐PCI. Moreover, IVUS was a valuable tool to confirm the true lumen course of the successful wire and to guide the stenting procedure. © 2012 Wiley Periodicals, Inc.     

Novel microsnare successfully used to remove small debris from the right coronary artery

Soutenir (Asahi-Intecc, Nagoya, Japan), a novel microsnare, was used to grip and pull a retrograde guidewire through arteries with chronic total occlusions during percutaneous coronary intervention (PCI). Soutenir can pass through a microcatheter with a 0.020″ lumen, and it can easily enter distal lesions in the coronary artery. Here, we introduce a method for retrieving the tip of a broken intravascular ultrasound (IVUS) catheter by using this microsnare. We present the case of a 64-year-old man who was referred to our hospital for narrowing of the proximal right coronary artery (RCA). After IVUS examination, the catheter was removed from the artery with some difficulty, and the catheter tip broke. The broken tip remained in the RCA and was carried along with the blood to the distal part of the RCA. The conventional gooseneck snare and filter device failed to retrieve the broken tip. However, Soutenir easily passed beyond the catheter tip and reached the distal part of the atrioventricular branch. It snared the tip of the catheter, whereby the tip could easily be removed. Thus, without damaging the RCA, we successfully removed the broken catheter tip from the RCA using this microsnare.     

Aortic root and extensive coronary dissections complicating recanalization of chronic right coronary artery occlusion: refraining from stenting may have a favorable outcome!

Aortic root dissection is a rare, potentially life-threatening complication of revascularization procedures. We report a case of recanalization of chronic total occlusion of the right coronary artery. A huge coronary dissection with a false lumen was created using commercially available guidewires during attempts to establish a connection with the distal true vessel lumen. In addition, an aortic root dissection from the right coronary cusp occurred. The patient was asymptomatic and a decision was made to refrain from stent deployment in order not to close communications between the false, true lumen and branches. The hospital stay was uneventful and the patient was discharged on conservative management. Control angiography at 3 months revealed patency of the right coronary artery with complete healing of the aortic wall dissection and improved clinical status of the patient.     

Simulation of a coronary vascular complication in transluminal coronary angioplasty by reversible intima folding

The injection of contrast material into the right coronary artery via a guiding catheter while a Harzler dilatation catheter had already been introduced revealed an inhomogeneous filling of the vessel suspicious of an extensive thrombosis or a dissection. On completion of the angioplasty and removal of the balloon catheter, the artery again filled homogeneously showing a good angioplasty result. It is concluded that a complication had only been faked during angioplasty due to intimal folding and subsequent flow obstruction following the insertion of the balloon catheter.     

Subintimal angioplasty of an aortoiliac occlusion: re-entry site created using a transseptal needle under intravascular ultrasound guidance.

PURPOSE: To report the use of a transseptal needle to cross the intimal flap in subintimal angioplasty of a flush aortoiliac occlusion via a retrograde approach. CASE REPORT: A 53-year-old man with claudication of the right lower limb and an angiographically documented right aortoiliac occlusion was treated with subintimal angioplasty via an ipsilateral retrograde approach. After puncture of the right common femoral artery, a 0.035-inch hydrophilic guidewire was advanced via the subintimal space toward the aortic true lumen, but the wire could not re-enter the true lumen. A transseptal needle was used to puncture the intimal flap under intravascular ultrasound (IVUS) guidance. Angioplasty/stenting was performed successfully, and the patient's symptoms were relieved. Computed tomography at 15 months revealed patent stents. CONCLUSION: The use of a transseptal needle to cross the intimal flap in total aortoiliac occlusions is technically feasible under IVUS guidance and enables successful angioplasty.     

CT coronary angiography-guided percutaneous coronary intervention for chronic total occlusion combined with retrograde approach

Percutaneous coronary intervention was performed for chronic total occlusion (CTO) of the right coronary artery (RCA) in a 55-year-old man. CT coronary angiography (CTCA) with a 64-slice scanner showed a large calcified plaque at the entrance to the CTO. A stent that had been implanted at the RCA ostium 10 years earlier was angled toward a side branch, suggesting that the guidewire would not reach the true lumen via the antegrade approach. Therefore, we attempted the retrograde approach via a septal collateral with the kissing wire technique. However, the guidewire failed to cross the CTO because of obstruction by the implanted stent. We next attempted the controlled antegrade and retrograde subintimal tracking technique and 2 stents were successfully deployed. In this patient, CTCA provided useful information for management of a difficult CTO.     

Retrograde Opacification of Collaterals Aiding Repeat PTCA of Complete Occlusion at Previously Dissected Angioplasty Site

During percutaneous transluminal coronary angioplasty the correct intravascular placement of an angioplasty guidewire and balloon is important especially when crossing a site of previous intimal dissection. This may be hazardous when total occlusion prevents anterograde opacification of the artery. This case illustrates the technique of retrograde opacification of the distal vessel by cross-filling from the contralateral coronary artery.     

Coronary artery dissection caused by exit of the guidewire through the distal perfusion sidehole of an auto-perfusion angioplasty balloon catheter

A previously unrecognized cause of coronary artery dissection is reported. A 67-year-old woman underwent angioplasty of the right coronary artery using an autoperfusion balloon catheter. Dissection occurred because the balloon catheter was advanced while the guidewire exited from one of the distal perfusion sideholes. © Wiley-Liss, Inc.     

经桡动脉普通导引导管7F无鞘技术治疗冠状动脉复杂病变

目的 评价经桡动脉普通导引导管7F无鞘技术治疗冠状动脉复杂病变的安全性、可行性.方法 纳入2013年11月至2014年4月,经桡/尺动脉置入6F桡动脉鞘造影后,需要用7F导引导管行介入治疗的患者31例.在桡动脉鞘内置入长260 cm,直径0.036 in（1 in=2.54 cm）非亲水涂层导丝至升主动脉;撤出桡动脉鞘,将6 F 110 cm猪尾管插入7 F 100 cm导引导管内,猪尾管头端突出于导引导管外;将猪尾管和导引导管呈一体,穿入长260 cm,直径0.036 in导引导丝,通过皮肤切口逐次进入桡动脉,导引导管到位后撤出猪尾管.结果 31例导引导管均成功通过桡动脉,到达靶冠状动脉开口,完成介入治疗后撤出导引导管.术后观察24 h,所有患者桡动脉穿刺处无出血,穿刺侧上肢未发生血肿、感觉障碍.术后1个月随访,未发生桡动脉闭塞.结论 经桡动脉普通导引导管7F无鞘技术是治疗冠状动脉复杂病变可选用的相对安全、有效的途径.     

Mechanical reperfusion of acute right coronary artery occlusion after radiofrequency catheter ablation and long-term follow-up angiography

Coronary artery injury is a rare complication of radiofrequency catheter ablation. We describe the case of a 12-year-old girl who had an acute distal right coronary artery (RCA) occlusion during radiofrequency catheter ablation of a postero-septal accessory pathway treated with mechanical reperfusion utilizing an angioplasty guidewire. Coronary angiography performed at 1-year follow-up depicted normal left ventricular function, patent descending posterior artery and total occlusion of the postero-lateral branch, which was filled through a rich collateral circulation from the RCA marginal branch.     

Potent Stent-Less Procedure Using Rotational Atherectomy and Drug-Coated Balloon to Right Coronary Ostial Lesion

BackgroundEven in the drug-eluting stent era, ostial lesion of the right coronary artery (RCA) still remains therapeutic challenge for interventional cardiologists. Case Series Case 1 (76 y.o. male) with angina on effort underwent transradial stent-less percutaneous coronary intervention (PCI) using rotational atherectomy (RA) followed by drug-coated balloon (DCB) dilation alone (RA/DCB) against a calcified de novo RCA ostial lesion. Case 2 (86 y.o. female) with recurrent unstable angina and hemodialysis underwent transfemoral RA/DCB against a severe repeat in-stent restenosis probably due to calcified nodule in the RCA ostium. In the both patients, PCI was successfully completed under intravascular ultrasound imaging (IVUS) guidance without complications. Follow-up CAG performed 4–5 months after the procedure revealed no significant lumen narrowing in the both RCA ostial lesions.ConclusionsThe both cases suggest that stent-less PCI using RA/DCB under IVUS might be an alternative revascularization therapy of choice for calcified RCA ostial lesions.     

Intravascular ultrasound in the management of acute coronary artery dissection: A case report

Crossing total occlusions is frequently difficult. The guidewire may enter a false lumen, thereby preventing successful balloon dilatations. We present a case of an acute arterial dissection following attempted angioplasty of a totally occluded right coronary artery. With an intravascular ultrasound probe in the false lumen, we were able to visualize a second guidewire and direct its passage into the true arterial lumen. This allowed for successful balloon dilatation and stent deployment restoring vessel patency.     

Successful revascularization of a long chronic total occlusion with blunt microdissection complicated by coronary artery dissection

We report a case of successful percutaneous revascularization of a chronic total occlusion using the LuMend Frontrunner catheter. The case was complicated by a long coronary artery dissection, with inability to access the true lumen. With favorable healing at 7 weeks, the true lumen was accessible which led to procedural success.