Abstract
Percutaneous coronary intervention (PCI) outcomes of chronic total occlusions (CTO) lesions have improved in recent years due to a better understanding of the physiopathology of the disease, more effective techniques and improvement in the design of new devices. We describe a new use of the Tornus® Catheter in the anterograde approach for CTO treatment.
1
Introduction
The development of techniques to facilitate recanalization of chronic total occlusions (CTO) is an area of active interest in interventional cardiology and still remains a technical challenge . The difficulty in its treatment is reflected in a lower success rate compared to other lesions (40% vs 98%) . The treatment benefits include symptom relief, improvement in left systolic ventricular function and better long-term survival .
The main cause of procedural failure is the inability to cross the CTO with a guide-wire, which may occur in up to 70%–80% of failure cases [4,5]. The presence of a bifurcation or a trifurcation at the proximal or distal entry point of the CTO has been described as an anatomical predictor of failure . When the distal cup of the occlusion ends in a bifurcation it has been reported that the wire tends frequently to advance up to the distal side branch, which is a “locus minori resistentiae” compared to the true distal main vessel lumen . In this situation very often the wire also slides in a sub intimal layer. Exchange for a stiffer wire or the use of the parallel wire technique does not always help to penetrate the stiff distal cap of the CTO. The Tornus© catheter (Asahi Intecc, Aichi, Japan) is a device used in two situations: 1) to give better support compared to a micro-catheter for crossing the CTO in calcified lesions; 2) once the guide-wire has crossed the occlusion the Tornus catheter is able to create a small channel in “a non dilatable CTO” that allows its posterior dilatation .
We hereby describe a new technique which can help to cross-distal bifurcated CTO lesions, combining the use of Tornus© catheter into the distal side branch.
2
Technique description
In three different patients with CTO lesions anterograde approach was performed. In all cases the CTO was located in the right coronary artery.
In the first patient after advancing the guide-wire (Fielder XT, Asahi Intecc, Aichi Japan) supported by a micro catheter through the body of the CTO lesion, distal cap was not crossed. By parallel wiring technique with a Miracle 3 (Asahi Intecc, Aichi Japan), distal side branch was reached. After several attempts we never succeeded to progress the wire into the distal true lumen of the main vessel. At this moment the wire was left in the side branch and a Tornus® catheter was advanced creating a micro channel through the CTO body. After removing the Tornus® catheter, we succeeded to redirect the Miracle 3 guide-wire towards the true lumen of the main branch. This is the simplest scenario to apply the described technique ( Fig. 1 ).
The second patient presented failure of redirecting the wire after Tornus® catheter micro-channel to the side branch. At this moment we decided to leave the Fielder guide-wire on the side branch and upgrade to a stiffer wire Confianza (Asahi Intecc, Aichi Japan) to successfully cross the CTO calcified body into the main branch and perform the percutaneous coronary intervention (PCI) ( Fig. 2 ).
In our third patient, after creation of the micro-channel with the Tornus® catheter in direction to the side-branch, a parallel wire technique was applied due to advancement into the sub-intimal space after the bifurcation, allowing the access to the distal true lumen and finishing the PCI.
2
Technique description
In three different patients with CTO lesions anterograde approach was performed. In all cases the CTO was located in the right coronary artery.
In the first patient after advancing the guide-wire (Fielder XT, Asahi Intecc, Aichi Japan) supported by a micro catheter through the body of the CTO lesion, distal cap was not crossed. By parallel wiring technique with a Miracle 3 (Asahi Intecc, Aichi Japan), distal side branch was reached. After several attempts we never succeeded to progress the wire into the distal true lumen of the main vessel. At this moment the wire was left in the side branch and a Tornus® catheter was advanced creating a micro channel through the CTO body. After removing the Tornus® catheter, we succeeded to redirect the Miracle 3 guide-wire towards the true lumen of the main branch. This is the simplest scenario to apply the described technique ( Fig. 1 ).
