Balloon uncrossable and balloon undilatable lesions






Balloon uncrossable lesions


CTO Manual Online cases: 1 , 5 , 15 , 18 , 27 , 30 , 31 , 47 , 49 , 52 , 53 , 57 , 73 , 124 , 126


PCI Manual Online case: 17 , 64 , 99


Balloon uncrossable lesions are lesions that cannot be crossed with a balloon after successful guidewire crossing.


Fig. 23.1 outlines a step-by-step algorithm for approaching such lesions.




Figure 23.1


Algorithm for crossing a balloon uncrossable lesion. Yellow , plaque modification; green , increase support.



Small balloon





  • The first step when trying to cross a balloon uncrossable lesion is to use a small balloon ( Section 30.9.2 ).



  • Use single marker, rapid exchange compliant balloons with a low crossing profile (1.0, 1.20, 1.25, and 1.5 mm in diameter) and long length (20–30 mm). The balloon profile is highest at the marker segment, hence longer balloons may allow for deeper lesion penetration with the lower profile segment of the balloon before the balloon marker reaches the uncrossable segment of the lesion. The Blimp Balloon (IMDS, not available in the United States) may also help crossing such lesions.



  • The Sapphire Pro 1.0 mm (OrbusNeich), the Ryurei 1.0 mm (Terumo, not available in the United States), the Ikazuchi Zero (Kaneka, not available in the United States) and the NIC Nano 0.85 mm balloon (SIS, not available in the United States) are the lowest-profile balloons currently available and are, thus, the first choice for balloon uncrossable lesions.



  • Other options are the Threader (1.2 mm, Boston Scientific) and the Takeru (Terumo) balloon that have low crossing profiles and stiff shafts to facilitate advancement though challenging lesions.



  • The Threader (Boston Scientific) has a hydrophilic coating and 0.017 in. lesion entry profile. The Threader is available in both rapid exchange and over-the-wire versions. The rapid exchange Threader is preferred to the over-the-wire version for balloon uncrossable lesions, as it has more penetrating capacity (likely due to stiffer shaft). However, the over-the-wire Threader allows guidewire changes and contrast injection.



  • The Glider balloon (Teleflex) has a beveled tip and was developed to cross through the struts of stents during bifurcation stenting, but can also be useful in difficult to cross lesions, as it can be torqued to present alternative tip configurations to the lesion.



  • The Blimp balloon ( Section 30.9.3.4 ) may also help cross some of the balloon uncrossable lesions.



  • If the balloon stops advancing, it can be inflated while maintaining forward pressure. This may dilate the entry to the lesion and allow lesion crossing, sometimes even with the same balloon (“balloon wedge” technique).



  • If the balloon fails to advance, consider balloon rotation. Avoid rotating more than two to three times in each direction so as to prevent the balloon from getting “stuck” on the guidewire.



  • If the balloon fails to advance after inflation, the operator can reshape it using his or her fingers while applying vacuum, or try a new small balloon (balloons lose their original profile after inflation), or one manufactured by another company, as different crossing profile and tip characteristics may assist in crossing. Rapid exchange balloon catheters allow more pushability into the lesion.



  • Alternatively, one can attempt crossing with a larger 2.5–3.0 mm diameter rapid exchange balloon. Sometimes inflation with a larger diameter balloon just proximal to the lesion will disrupt the architecture of the lesion entry enough to allow subsequent passage of a small profile balloon or microcatheter.



What can go wrong ?



  • 1.

    Guide catheter and guidewire position can be lost during attempts to advance the balloon or microcatheter. Carefully monitor the guide catheter position and stop advancing if the guide catheter starts backing out of the coronary ostium or if the distal guidewire position is being compromised. Forceful back and forth balloon manipulation can cause ostial dissection, especially if there is a preexisting ostial lesion.


  • 2.

    Injury of the distal target vessel can occur (dissection or perforation) due to significant distal guidewire movement (“see-saw” action of wire with forward push and retraction of the balloon), especially when stiff (such as Confianza Pro 12, Asahi) or polymer-jacketed (such as the Pilot 200, Abbott Vascular) guidewires are used.


  • 3.

    Balloon entrapment can occur within the lesion, although this is highly unlikely.




Grenadoplasty (intentional balloon rupture; also called “balloon assisted microdissection” or “BAM”)


This is a simple, safe, and often effective technique, that is increasingly being used in the treatment algorithm for balloon uncrossable lesions .


How ?


A small (usually 1.0–1.5 mm) balloon is advanced as far as possible into the lesion and inflated at high pressure until it ruptures ( Fig. 23.2 ) . When the balloon ruptures, suction should immediately be applied through the inflating device to avoid unnecessary barotrauma to the vessel. The balloon rupture can often sufficiently modify the plaque, resulting in subsequent successful crossing with a new balloon.




Figure 23.2


Illustration of the grenadoplasty technique to cross a distal right coronary artery balloon uncrossable CTO. The lesion could not be crossed despite using an 8 Fr Amplatz guide and an anchor balloon ( arrowhead , panel A). A 1.2 mm balloon was ruptured with contrast spreading proximally and distally ( arrows , panel A). A Finecross microcatheter could then be advanced through the lesion followed by wire exchange and a 2.0 mm balloon with an excellent final result (panel B).

Courtesy of Dr. Gabriele Gasparini. Reproduced with permission from Brilakis ES. Manual of coronary chronic total occlusion interventions. A step-by-step approach. 2nd ed. Cambridge, MA: Elsevier; 2017 (Figure 8.2).


What can go wrong ?



  • 1.

    Proximal vessel dissection and perforation. This is extremely unlikely when small (1.0–1.5 mm) balloons are used. Larger balloons (≥ 2.0 mm) should NOT be used for grenadoplasty.


  • 2.

    The balloon should be meticulously prepared to empty all air and hence minimize the risk of air embolism.


  • 3.

    Watching the indeflator rather than the screen allows more rapid deflation of the balloon immediately upon rupture. This will reduce the chance of pinhole contrast-induced vessel injury from the rupture site of the balloon.


  • 4.

    One may encounter difficulty removing the ruptured balloon. In some cases, the ruptured balloon becomes entangled with the guidewire, requiring removal of both, hence losing guidewire position.




Increase support


Increasing support is critical for crossing a balloon uncrossable lesion and is discussed in detail in Section 9.5.8. Key elements for increasing support are the guide catheter and the guidewire.



Guide catheter


Better guide catheter support increases the likelihood of successful balloon or microcatheter crossing. Guide support can be increased by using larger guide catheters with supportive shapes, using femoral access, forward push or deep intubation, guide catheter extensions and various anchoring techniques , as described in detail in Sections 9.5.8.1–9.5.8.7. Changing guide catheter after guidewire crossing can be challenging and may lead to guidewire position loss, which may not be acceptable in some cases (such as chronic total occlusions).



Guide catheter extension


How ?


A Guideliner (Teleflex), Guidezilla (Boston Scientific), Guidion (IMDS), or Telescope (Medtronic) guide catheter extension ( Section 30.3 ) is advanced into the vessel, enhancing guide catheter support and the pushability of balloons/microcatheters. In a randomized trial, use of a 5-in-6 guide catheter extension was more effective and efficient in facilitating the success of transradial PCI for complex coronary lesions, as compared with buddy-wire or balloon-anchoring .


What can go wrong ?



  • 1.

    Guidewire and guide catheter position loss or distal vessel injury during attempts to advance the guide catheter extension.


  • 2.

    Guide catheter extension advancement can cause ostial or mid target vessel dissection . When a guide extension catheter is advanced distally into a wedged position, a dampened pressure tracing is observed, and guide catheter injections are avoided due to high risk of hydraulic dissection and damage to the proximal vessel.


  • 3.

    Dislodgement of the guide catheter extension distal marker can also occur .


  • 4.

    When equipment is advanced through the guide catheter extension, another potential complication is deformation or separation (stripping) of the stent from the stent balloon during attempts to advance it through the guide catheter extension proximal “collar.” This may occur around the subclavian curve with radial access, hence consider using guide catheter extensions with a long (40 cm instead of 25 cm) cylinder length in radial access cases.




Anchor strategies


How ?



  • 1.

    Side branch anchor technique ( Fig. 23.3 ). A workhorse guidewire is advanced into a side branch (usually a conus or acute marginal branch for the right coronary artery or a diagonal for the left anterior descending artery), followed by a small balloon (usually 1.5–2.0 mm in diameter depending on the side branch vessel size). The balloon is inflated usually at 6–8 atm “anchoring” the guide into the vessel and enhancing advancement of balloons, stents or microcatheters. Sometimes, patients may develop chest pain during inflation of the balloon in the side branch .




    Figure 23.3


    Illustration of the side branch anchor technique for treating a balloon uncrossable lesion.

    Modified with permission from Brilakis ES. Manual of coronary chronic total occlusion interventions. A step-by-step approach. 2nd ed. Cambridge, MA: Elsevier; 2017 (Figure 8.4)


  • 2.

    Buddy wire stent anchor (Section 9.5.8.1.7). If the proximal vessel requires stenting, a buddy wire can be inserted and a stent deployed over it, effectively “trapping” the buddy wire, which then provides strong guide catheter support.


  • 3.

    Both antegrade and retrograde anchoring can be performed in challenging retrograde CTO PCI cases .



What can go wrong ?



  • 1.

    Guidewire and guide catheter position loss or distal vessel injury can occur during attempts to advance an anchor balloon.


  • 2.

    A side branch anchor can cause injury or dissection of the side branch, however this is infrequent and usually does not lead to significant adverse consequences.


  • 3.

    Perforation of the side branch may rarely occur. Oversizing of the anchor balloon should be avoided to minimize the risk of both side branch perforation and dissection and a workhorse wire should be used to minimize wire-related vessel injuries.


  • 4.

    Potential risks of the “buddy wire stent anchor” technique include: inability to remove the buddy wire or failure to advance equipment through the proximal stent.




Guidewire


Guidewire exchange may not be feasible or desirable in difficult to cross lesions, such as chronic total occlusions. However, leaving the original guidewire in place and crossing the lesion with a second guidewire may succeed and can sometimes be performed through a second guide catheter .


Using a support guidewire, a Wiggle guidewire, or the deep wiring technique can significantly facilitate crossing of balloon uncrossable lesions, as described in Section 9.5.8.2.



Microcatheter advancement


How ?



  • 1.

    The concept behind use of a microcatheter is that advancement of a microcatheter through the lesion can modify the occlusion, enabling subsequent crossing with a balloon.


  • 2.

    There are several microcatheters that can be utilized as described in Section 30.6 .


  • 3.

    The following microcatheters are especially designed for balloon uncrossable lesions ( Section 30.6.5 ):




    • The Tornus catheter (Asahi Intecc) was designed for advancing through calcified and difficult to penetrate lesions and should be advanced using counterclockwise rotation and withdrawn using clockwise rotation .



    • The Turnpike Spiral and Turnpike Gold catheters (Teleflex) were also designed with threads to “screw into the lesion” and modify it. In contrast to the Tornus catheter, they are advanced by turning clockwise and withdrawn by turning counterclockwise.



  • 4.

    Standard microcatheters can also be used:




    • The Corsair Pro and Corsair XS microcatheters (Asahi Intecc) ( Section 30.6.1 ) can be advanced by rotating in either direction (in contrast to the Tornus catheter).



    • The Turnpike and Turnpike LP catheters (Teleflex) ( Section 30.6.1 , Section 30.6.2 ) can also be rotated in either direction.



    • Similarly, the Finecross (Terumo) or MicroCross 14 (Boston Scientific) ( Section 30.6.2 ) can be rotated in either direction, although rotation may be challenging and there is a risk of tip dislodgement if aggressively torqued.



    • The Caravel (Asahi Intecc) is a low-profile microcatheter, but is not designed for aggressive torquing as is often done with the Corsair and Turnpike family of microcatheters and should generally not be used in balloon uncrossable lesions to minimize the risk of tip fracture and separation.



  • 5.

    If successful advancement of a microcatheter is achieved, a balloon can often subsequently cross the lesion. Alternatively, the guidewire can be exchanged for a more supportive guidewire or an atherectomy wire ( PCI Manual Online case: 64 ), if the latter is planned as the next lesion preparation step.



What can go wrong ?



  • 1.

    Guide catheter and guidewire position may be lost with aggressive pushing of the microcatheters.


  • 2.

    Distal vessel injury can occur from uncontrolled guidewire movement during microcatheter advancement attempts.


  • 3.

    The microcatheter can get damaged if overtorqued, leading to catheter tip entrapment or tip/shaft fracture. If the tip of the microcatheter breaks off it can become entrapped in the lesion. Rotation should not exceed 10 turns before allowing the catheter to “unwind.” A guidewire should always be kept within the microcatheter lumen to prevent kinking and possible entrapment. If the tip of the microcatheter breaks off it can become entrapped in the lesion.


  • 4.

    Rarely, excessive manipulation of the microcatheter can disrupt the device and/or the guidewire and lock both devices together, requiring withdrawal of both. A polymer-jacketed guidewire can sometimes be advanced through the track that has been established, allowing the crossing attempts to restart.




Wire-cutting


See Fig. 23.4 .




Figure 23.4


Illustration of the wire-cutting (A) and seesaw wire-cutting (B) techniques.

Reproduced with permission from Brilakis ES. Manual of coronary chronic total occlusion interventions. A step-by-step approach. 2nd ed. Cambridge, MA: Elsevier; 2017 (Figure 8.3).


How ?



  • 1.

    A second guidewire is advanced through the lesion (which may be challenging to accomplish).


  • 2.

    A balloon is advanced over the first guidewire, as far as possible into the proximal cap and inflated.


  • 3.

    The second guidewire is withdrawn while the balloon is inflated, effectively “cutting” the proximal cap and modifying it.


  • 4.

    After deflation and removal of the original balloon, a new balloon is advanced over the first guidewire, often successfully crossing the modified lesion.


  • 5.

    A modified version of this technique is the “ seesaw wire-cutting technique .” In this technique two balloons are advanced over the two guidewires (one balloon over each wire). One of the balloons is first advanced as distally as possible and inflated, pressing the other wire against the proximal cap. The first balloon is then pulled back and the other balloon is advanced distally and inflated producing a similar cutting effect to modify the cap on the other side. This process is repeated multiple times until one of the balloons crosses the lesion. A retrospective study of 80 patients found this technique to be associated with higher device and procedural success rates and shorter procedure time as compared with use of the Tornus catheter .



What can go wrong ?



  • 1.

    Withdrawal of the second guidewire may result in deep intubation of the guide catheter, potentially leading to ostial or proximal vessel dissection. This complication can be prevented by carefully watching the guide catheter during withdrawal of the second guidewire, and promptly backing it out of the vessel as needed. If, however, a dissection occurs it could be used for subintimal wire advancement and subintimal lesion modification (or subintimal distal anchor) as described in Section 23.1.8 , provided that the operator has experience with these techniques.




Wire puncture


How ?



  • 1.

    A stiff guidewire (such as Hornet 14 [Boston Scientific] or Confianza Pro 12 [Asahi Intecc]) is advanced to the lesion over a microcatheter or over-the-wire balloon.


  • 2.

    The lesion entry is “punctured” or “jabbed” several times with the stiff guidewire tip, which may modify the lesion and facilitate equipment crossing.


  • 3.

    Advancing a supportive second guidewire through the balloon uncrossable lesion may in itself facilitate lesion crossing with a balloon or microcatheter.



What can go wrong ?



  • 1.

    Perforation, although this is unlikely even if the guidewire exits the vessel architecture (unless it is followed by a balloon or microcatheter).




Laser





  • Online video: “ Impact of contrast on laser activation



  • PCI Manual Online cases: 23 , 64



  • CTO Manual Online cases: 5 , 18 , 27 , 47 , 52 , 73


    Laser atherectomy ( Section 30.11 ) is increasingly utilized for balloon uncrossable and balloon undilatable lesions, in part because laser atherectomy can be performed over any standard 0.014 in. guidewire in contrast to rotational and orbital atherectomy, which require dedicated guidewires .


    How ?



    • 1.

      The 0.9 mm excimer laser atherectomy catheter should be used, usually at maximum repetition and fluence levels (repetition rate 80 Hz and fluence of 80 mJ/mm 2 ) . The coronary laser catheter is programmed to minimize the risk of coronary ischemia, with laser activation designed to work with a slow, continuous saline infusion , however the peripheral “turbo elite” catheter (Philips) is generally preferred over the coronary catheter since it does not automatically stop after 10 seconds of treatment. The laser can modify the uncrossable segment and facilitate balloon entry into the lesion .


    • 2.

      The laser console requires a 5-minute warming period as well as calibration prior to use. Anticipating its potential use and setting up the system early can minimize delays and improve the efficiency of the procedure.


    • 3.

      A variation of the above technique is to perform laser while injecting contrast through the guide catheter or via the over-the-wire side port of the laser catheter itself (if an over-the-wire laser is used, which is more commonly done in peripheral arteries and rarely in coronary arteries). Laser activation with simultaneous contrast injection can cause profound plaque modification through the acousticomechanical effect of the rapidly exploding bubbles. Laser with contrast, however, increases the risk of vessel injury and/or perforation and should generally only be done within previously deployed stents.




What can go wrong ?



  • 1.

    Vessel perforation, especially when performing laser in tortuous coronary vessels ( PCI Manual Online case: 55 ). The risk may be higher when the high laser settings are used (repetition rate 80 Hz and fluence of 80 mJ/mm 2 ) and when contrast is injected; the risk is lower when laser is activated within previously placed stents.


  • 2.

    Laser activation over polymer-jacketed guidewires can result in polymer damage, making the wire “sticky” or “gummy.”




Atherectomy


How ?



  • 1.

    Rotational or orbital atherectomy ( Section 30.10 and Chapter 19 : Calcification) can greatly facilitate lesion crossing with a balloon. These atherectomy modalities, however, require wire exchange for a dedicated guidewire (Rotawire floppy or Rotawire extra support for rotational atherectomy and ViperWire Advance or ViperWire Advance Flex Tip for orbital atherectomy), which may not always be feasible through a balloon uncrossable lesion .


  • 2.

    If no other maneuver is successful in crossing the balloon uncrossable lesion, it is sometimes possible to “bury” a microcatheter as far as possible into the lesion, pull the original guidewire, and attempt to rewire with a dedicated atherectomy guidewire. If rewiring is successful, then atherectomy can be performed.


  • 3.

    Rotational atherectomy may be advantageous over the current version of orbital atherectomy in balloon uncrossable lesions, as it provides forward “end-on” cutting in contrast to orbital atherectomy that provides “sideways” cutting.


  • 4.

    Atherectomy will differentially cut calcific tissue but will not cut through elastic tissue, such as the adventitia.



What can go wrong ?



  • 1.

    Loss of guidewire position across the lesion (if the guidewire has to be removed and replaced with a dedicated atherectomy guidewire) that may fail to recross the lesion.


  • 2.

    Vessel perforation, which is why a small diameter rotational atherectomy burr (1.25–1.50 mm) is preferred. The risk of perforation may be higher with atherectomy in the subintimal space.


  • 3.

    Burr entrapment upon forceful forward advancement. The burr should be advanced in a repetitive and gentle manner avoiding forceful “wedging” into the occlusion with burr deceleration. Prevention and management of this complication is discussed in Chapter 19 , Calcification, Section 19.9.5.7.3 .




Subintimal techniques


CTO Manual Online case: 1


Subintimal techniques ( Fig. 23.5 ) can significantly facilitate treatment of “balloon uncrossable” lesions, but the operators need to be experienced in the use of these CTO PCI techniques.


Feb 4, 2021 | Posted by in CARDIOLOGY | Comments Off on Balloon uncrossable and balloon undilatable lesions
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