Ping-Pong Guide Catheter Technique for Retrograde Intervention of a Chronic Total Occlusion Through an Ipsilateral Collateral

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1 Catheterization and Cardiovascular Interventions 78: (2011) Case Reports Ping-Pong Guide Catheter Technique for Retrograde Intervention of a Chronic Total Occlusion Through an Ipsilateral Collateral Emmanouil S. Brilakis, 1 * MD, PhD, FSCAI, J. Aaron Grantham, 2 MD, and Subhash Banerjee, 1 MD, FSCAI We report a novel technique for performing retrograde interventions on a coronary chronic total occlusion through an ipsilateral collateral. Two guiding catheters are used to engage the target coronary artery, one to advance to the retrograde guidewire and the other to externalize the retrograde guidewire and antegrade wiring. Engagement of the target coronary artery is alternating between the antegrade and the retrograde guide catheter in a ping-pong fashion, enabling lesion crossing and equipment delivery. VC 2011 Wiley-Liss, Inc. Key words: chronic total occlusion; percutaneous coronary intervention; technique INTRODUCTION Retrograde intervention of a coronary chronic total occlusion (CTO) can be performed via a saphenous vein graft [1], a septal [2], or an epicardial [3] collateral vessel. Although most collateral vessels originate from the opposite coronary artery, in some patients, ipsilateral collaterals supply the distal to CTO coronary segment and can be used for retrograde CTO percutaneous coronary intervention (PCI) [4,5]. We describe a case in which retrograde CTO PCI through an ipsilateral collateral was accomplished by using a second ipsilateral guiding catheter for retrograde wire externalization. Engagement of the target coronary artery alternated between the antegrade and retrograde guide catheter in a ping-pong fashion. CASE REPORT A 43-year-old man presented with severe exertional angina refractory to nitrate and beta blocker administration. His risk factors for coronary artery disease included smoking and hyperlipidemia. He had undergone stenting of the proximal right coronary artery (RCA) with six bare metal stents 7 years before presentation, and the stents were angiographically documented to be occluded 3 years before presentation. Nuclear exercise stress testing revealed inferior ischemia. Diagnostic coronary angiography demonstrated no significant stenoses in the left main, left anterior descending, and circumflex arteries and occlusion of the proximal RCA due to in-stent restenosis (Fig. 1A). The distal RCA was filling mainly via an ipsilateral atrial collateral (Fig. 1B and C). The patient elected to attempt PCI of the RCA CTO. The RCA was engaged with a 7 French JR4 guide catheter, and anticoagulation was achieved with 1 VA North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 2 Saint Luke s Health System s Mid-America Heart Institute, University of Missouri Kansas City School of Medicine, Kansas City, Missouri Conflict of interest: Dr. Brilakis: Speaker honoraria from St Jude Medical; consulting fees from Medicure; research support from Abbott Vascular; salary from Medtronic (spouse); Dr. Grantham: none; Dr. Banerjee: Speaker honoraria from St. Jude Medical, Medtronic, and Johnson & Johnson and research support from Boston Scientific and The Medicines Company. Presented at the 2010 TCT meeting in Washington, DC. *Correspondence to: Emmanouil S. Brilakis, MD, PhD, FSCAI, VA North Texas Health Care System, The University of Texas Southwestern Medical Center at Dallas, Division of Cardiology (111A), 4500 S. Lancaster Rd, Dallas, TX esbrilakis@yahoo.com Received 6 October 2010; Revision accepted 10 October 2010 DOI /ccd Published online 16 March 2011 in Wiley Online Library (wileyonlinelibrary.com) VC 2011 Wiley-Liss, Inc.

2 396 Brilakis et al. Fig. 1. Coronary angiography demonstrating a proximal right coronary artery (RCA) CTO due to in-stent restenosis (arrows, panel A), with an ipsilateral atrial collateral (arrows, panel B). Bilateral injection revealed collateral filling of the distal RCA from ipsilateral and contralateral collaterals (panel C). Selective injection of the atrial collateral through a Finecross catheter showed a continuous connection (arrows, panel D). unfractionated heparin. An attempt to antegradely cross the lesion using several guidewires (Miracle Bros 3, 6, and Confianza Pro 12, Abbott Vascular, Santa Clara, CA) failed. The atrial collateral branch was wired with a Fielder FC wire (Abbott Vascular), and selective injection through a Finecross catheter (Terumo, Somerset, NJ) confirmed the presence of a continuous connection with the distal RCA (Fig. 1D). The Fielder FC wire easily crossed the collateral vessel into the distal RCA (Fig. 2A) and was exchanged for a Provia 3 wire (Medtronic Vascular, Santa Rosa, CA) that partially penetrated the distal CTO cap (Fig. 2B). A Provia 9 wire (Medtonic Vascular) successfully crossed the CTO into the ascending aorta (Fig. 2C and D). We initially attempted to perform retrograde balloon angioplasty, but could not cross the lesion with a 1.5- mm balloon. We were unable to advance the retrograde guidewire into the JR4 guiding catheter. We inserted a second 7 French JR4 guiding catheter through which the retrograde guidewire was snared with a 25 mm Amplatzer Gooseneck snare (ev3, Plymouth, MN) (Fig. 3A and B) and externalized. An intravascular ultrasound catheter inserted antegradely over the externalized guidewire confirmed that the guidewire was located within the true vessel lumen (Fig. 3C and D). The retrograde guidewire

3 Ping-Pong Technique for Retrograde CTO PCI 397 was covered by the Finecross catheter (Terumo) within the collateral vessel. After predilation, the mid RCA was stented with a mm Xience V everolimus-eluting stent (Abbott Vascular) delivered antegradely over the retrograde guidewire. To avoid entrapment of the retrograde guidewire, another wire was inserted antegradely through the lesion (Fig. 4B) and the retrograde guidewire and guide catheter were removed. A mm Xience V everolimus-eluting stent (Abbott Vascular) was deployed in the proximal RCA (Fig. 4C) resulting in an excellent final angiographic result (Fig. 4D). The patient s angina resolved, and he has remained chest pain free without receiving any anti-anginal medications during 4 months of follow-up. DISCUSSION Fig. 2. Crossing of the atrial collateral with a Fielder FC guidewire (Abbott Vascular) (arrow, panel A), followed by retrograde CTO crossing with a Provia 3 (panel B) and a Provia 9 (panel C) (Medtronic Vascular) guidewire into the aorta (arrow, panel D). We describe the ping-pong guide catheter technique that can facilitate retrograde CTO PCI through an ipsilateral collateral. CTO PCI through an ipsilateral collateral has been described via septal to septal collaterals in left anterior descending artery CTOs [4,5]. Our case demonstrates that a similar technique can be applied for atrial collaterals in the RCA, which may be better suited for ipsilateral retrograde PCI, as they may be less angulated than the septal to septal collaterals [4]. However, they may also be associated with higher risk of tamponade, in case of collateral vessel rupture. Once the retrograde guidewire is advanced to the distal cap, subsequent treatment options include the following: (a) using the retrograde guidewire as a marker of the distal true lumen while attempting antegrade wiring ( just marker technique ); (b) retrograde true lumen puncture; (c) subintimal dissection techniques, such as the Controlled Antegrade and Retrograde Tracking and Dissection (CART), where a retrograde balloon is inflated in the subintimal space followed by antegrade wire crossing) [6] and the reverse CART (antegrade balloon inflation in the subintimal space

4 398 Brilakis et al. Fig. 3. Snaring and externalization of the retrograde guidewire (panels A and B). Intravascular ultrasonography (arrow, panel C) confirmed intraluminal wire position (panel D). followed by retrograde wire crossing in the proximal true lumen) techniques. In the present case, antegrade wiring was not feasible likely due to long duration of the occlusion [7]. Retrograde wiring successfully crossed the CTO without entering the subintimal or substent space, as confirmed by intravascular ultrasonography. Once the retrograde guidewire enters the proximal true lumen, as in our patient, the following treatment options exist: (a) retrograde balloon dilation of the CTO, followed by antegrade wiring; (b) exchange of the retrograde guidewire with an antegrade guidewire using a variety of specialized techniques [8]; (c) wire externalization; or (d) retrograde stent delivery. The first option is the simplest, but, in our patient, a balloon could not be advanced retrogradely through the CTO. We were unable to exchange the wire or externalize it, because it entered the aorta and could not be advanced into the guide catheter. By inserting a second JR4 guide catheter and by alternating engagement of the RCA ( ping-pong guide catheter technique), we were able to snare the retrograde guidewire and externalize it, followed by successful antegrade stent delivery. Alternatively, instead of externalizing the retrograde guidewire, we could have trapped it into the second guide catheter to enhance support for delivering a retrograde balloon into the CTO, which would have not been feasible with a single guide catheter. If the retrograde guidewire had re-entered the initial guide catheter, theoretically, it could have been externalized through the same guide catheter, but this could have made equipment delivery challenging. Using the ping-pong guide, catheter technique has limitations. It requires a second arterial access, if this has not been originally obtained. Snaring of the retrograde guidewire may be challenging, but could be facilitated by use of large diameter snares. When stenting needs to be performed at the site of the ipsilateral collateral, as in our patient, the retrograde guidewire needs to be removed to avoid entrapment. As in any retrograde CTO PCI, injury of the collateral vessel can

5 Ping-Pong Technique for Retrograde CTO PCI 399 Fig. 4. After stenting of the mid right coronary artery (RCA; arrow, panel A), the RCA was wired antegradely (arrow, panel B) followed by proximal right coronary artery stenting (arrow, panel C) with an excellent final angiographic result (panel D). result in target vessel ischemia, especially if there few additional collateral vessels. In summary, use of a second guide catheter in cases of retrograde CTO PCI through an ipsilateral collateral in a ping-pong fashion may facilitate externalization of the retrograde guidewire and enhance the probability of procedural success. ACKNOWLEDGMENTS We gratefully acknowledge the tremendous support of the cardiac catheterization laboratory team at the Dallas VA Medical Center for enabling the development of novel catheterization techniques and the performance of clinical research. REFERENCES 1. Brilakis ES, Banerjee S, Lombardi WL. Retrograde recanalization of native coronary artery chronic occlusions via acutely occluded vein grafts. Catheter Cardiovasc Interv 2010;75: Surmely JF, Katoh O, Tsuchikane E, Nasu K, Suzuki T. Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv 2007;69: Brilakis ES, Badhey N, Banerjee S. Bilateral Knuckle technique and stingray re-entry system for retrograde chronic total occlusion intervention. J Invas Cardiol, in press. 4. Otsuji S, Terasoma K, Takiuchi S. Retrograde recanalization of a left anterior descending chronic total occlusion via an ipsilateral intraseptal collateral. J Invas Cardiol 2008;20: Utsunomiya M, Mukohara N, Hirami R, Nakamura S. Percutaneous coronary intervention for chronic total occlusive lesion of a left anterior descending artery using the retrograde approach via a septal-septal channel. Cardiovasc Revasc Med 2010;11: Surmely JF, Tsuchikane E, Katoh O, Nishida Y, Nakayama M, Nakamura S, Oida A, Hattori E, Suzuki T. New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: The CART technique. J Invas Cardiol 2006;18: Brilakis ES, Lombardi WB, Banerjee S. Use of the Stingray VR guidewire and the Venture VR catheter for crossing flush coronary chronic total occlusions due to in-stent restenosis. Catheter Cardiovasc Interv 2010;76: Kim MH, Yu LH, Mitsudo K. A new retrograde wiring technique for chronic total occlusion. Catheter Cardiovasc Interv 2010;75: