Abstract
Chronic total occlusion (CTO) revascularization is traditionally limited by the challenges related to lesion crossing. In a smaller number of cases, however, inability to advance the balloon catheter to the crossing site can account for recanalization failure (“balloon uncrossable” CTO). We describe a case of a “balloon uncrossable” CTO in which balloon crossing was achieved after subintimal dilation and “external crushing” of the CTO lesion resulting in significant modification of the CTO atheromatous plaque.
Highlights
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Balloon uncrossable chronic total occlusions of the coronary arteries are lesions in which there is difficulty to advance the balloon catheter at the lesion site after successful guidewire crossing.
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Dilation of a balloon in the subintimal space (“external crush”) at the level of a balloon uncrossable chronic total occlusion may alter the atheromatous plaque and resolve the case.
In the modern era, advances in equipment and development of newer techniques have streamlined percutaneous coronary intervention (PCI) for chronic total occlusion (CTO), enabling high CTO crossing rates . However, even following successful guidewire crossing, suboptimal lesion dilation and/or stent deployment can compromise final angiographic success . “Balloon uncrossable CTOs” are characterized by difficulty to advance the balloon catheter to the CTO crossing site, thus hindering lesion dilation. Available techniques to overcome this challenge focus on either modifying the atheromatous plaque (such as use of small diameter balloons, microcatheters such as Tornus (Asahi Intecc, Nagoya, Japan) or Finecross (Terumo, Somerset, NJ), laser, and rotational atherectomy) or enhancing guide catheter support (such as use of guide catheter extension and anchor techniques) . We recently described the “subintimal distal anchor” technique, in which a balloon was inflated over a subintimal guidewire distal to the occlusion to anchor the true lumen guidewire and facilitate balloon crossing . Herein, we present a case in which a balloon was inflated over a subintimal guidewire adjacent to the CTO, “crushing” the occluded segment and enabling balloon crossing over the true lumen guidewire.
A 59-year-old man with a history of diabetes, hypertension, hyperlipidemia, prior PCI and prior coronary artery bypass grafting surgery presented with worsening angina. Diagnostic coronary angiography revealed a right coronary artery (RCA) CTO ( Fig. 1 , panels A and B) with occluded RCA saphenous vein graft. The left anterior descending artery filled through a patent left internal mammary graft and the obtuse marginal branch was patent without significant stenoses. The patient was referred for RCA CTO intervention. Anticoagulation was achieved with unfractionated heparin and bilateral femoral access was obtained with 8 French sheaths. The right coronary artery was engaged with a 6 French AL1 guide catheter (a larger guide catheter was not used due to severe pressure dampening upon engagement) and the occlusion was crossed with a Pilot 200 guidewire (Abbott Vascular, Santa Clara, California) supported by a Corsair microcatheter (Asahi Intecc) ( Fig. 1 , panel C). Distal true lumen wire position was confirmed with contralateral injection from the left main coronary artery. We were unable to deliver a 1.5 mm or 1.25 mm balloon through the occlusion, even after intentional rupture of the 1.5 mm balloon (grenadoplasty). We were also unable to cross using a Tornus catheter and no wire anchoring options were feasible. We engaged the RCA with a second 6 French Champ 1 guide catheter and attempted to cross the lesion with a second Pilot 200 guidewire. The guidewire followed a subintimal course but did not re-enter into the distal true lumen. A 2.0 × 20 mm balloon was inflated over the second guidewire adjacent to the CTO “crushing” the occlusion ( Fig. 1 , panel D). A 1.5 mm balloon then easily crossed the CTO over the true lumen guidewire ( Fig. 1 , panel E), followed by a 2.0 × 20 mm and 2.5 × 20 mm balloon. The RCA was stented up to the ostium using everolimus-eluting stents with an excellent final result and TIMI 3 flow ( Fig. 1 , panel F). The patient had no complications and experienced complete angina relief.
This case describes a novel approach to “balloon uncrossable” CTOs, whereby “subintimal external crushing” of the CTO was employed to enable lesion crossing with a balloon ( Fig. 2 ).
