Special papers<br>Chronic total occlusion in ostium of right coronary artery – retrograde approach as the first-choice method of revascularization?

Postępy w Kardiologii Interwencyjnej 2013; 9, 4 (34) 337

Special paper

Chronic total occlusion in ostium of right coronary artery – retrograde approach as the first-choice method

of revascularization?

Leszek Bryniarski¹, Tomasz Kameczura¹, Sławomir Surowiec¹, Bogdan Januś², Bogusław Derlaga³, Dariusz Dudek⁴, Danuta Czarnecka¹

11^stDepartmentofCardiology,InterventionalElectrocardiologyandArterialHypertension,HospitalUniversity,CollegiumMedicum

JagiellonianUniversity,Krakow,Poland

2LaboratoryofHemodynamicsandElectrophysiology,EdwardSzczeklikSpecialityHospital,Tarnow,Poland

3DepartmentofInvasiveCardiology,EdwardSzczeklikSpecialityHospital,Tarnow,Poland

42^ndDepartmentofCardiologyandCardiovascularInterventions,HospitalUniversity,CollegiumMedicumJagiellonianUniversity,Krakow,

Poland

PostepKardiolInter2013;9,4(34):337–340

DOI:10.5114/pwki.2013.38861

A b s t r a c t

Recanalizationofchronictotalocclusion(CTO)locatedintheostiummayrequiretheoperator’sabilitytousetheretrograde

approach.Wepresentacaseofopeningachronicallyoccludedrightcoronaryartery(RCA)bytheretrogradeapproachafteranun- successfulattemptofrecanalizationbyclassicantegradetechnique.

Key words: chronictotalocclusion,retrogradetechnique,recanalization.

Introduction

Long-term analysis and clinical observation allows

separation of prognostic factors influencing successful

recanalization of chronic total coronary occlusion [1].

Localization and length of occlusion, the presence and

severityofcalcification,andpresenceofcollateralsand

sidebranchesatthesiteoftheocclusioncorrelatewith

thesuccessrateofrecanalizationinthecaseofproce- duresusingtheclassicantegradetechnique.Ostialcor- onaryarteryocclusionisaparticularformwhichisinter

aliaincludedintheSYNTAXScorealgorithm.Streamlin- ingthistypeofocclusionisdifficultandmayrequirethe

useofretrogradetechniques.Wepresentacaseofapa- tientwithchronicostialcoronaryarteryocclusion,treat- edbytheretrograde method,afterfailureoftheclassic

antegrade method.

Case report

The case concerns a 59-year-old male patient, with

obesity,numerousischemicheartdiseasefactors(hyper- cholesterolemia,arterialhypertension,diabetesmellitus

Corresponding author:

Prof. Leszek Bryniarski MD, PhD, 1^st Department of Cardiology, Interventional Electrocardiology and Arterial Hypertension, Hospital University, 17 Kopernika St, 31-501 Krakow, Poland, e-mail: l_bryniarski@poczta.fm

Received: 16.08.2013, accepted: 10.10.2013.

type2treatedbydiet),withahistoryofinferiorwallmyo- cardialinfarction(MI)inthepast,withexertionalchest

pain(CCSIII)for3months.Theexercisetestperformed

in ambulatory care was clinically positive at the work- loadof9METs.Echocardiographicexaminationrevealed

normalejectionfraction(EF–60%).InrestingECGthere

wasnopathologicalqafterMIbutanegativeTwavein

leadI,aVL,V5andV6wasfound.Coronarographyper- formedinaperipheralcathlabon29.04.2011revealed

occlusionintheproximalsegmentoftherightcoronary

artery(RCA)andnosignificantfindingsintheleftcor- onary artery (LCA). The operators decided to perform

theprocedureofopeningtheRCA.ForRCAintubations

theyusedaJR4.06Frcatheter.Afterinsertionofthe

BMWguidewireintothearteryventricularfibrillation

occurred. After successful resuscitation the operators

stoppedtheprocedure.Primarilythepatientwasqual- ified for pharmacological treatment of ischemic heart

disease,butbecauseofpersistentcomplaints(CCSan- ginaclassIII),thepatientwasqualifiedforPCIinaref- erencecenter(Figure1).

Postępy w Kardiologii Interwencyjnej 2013; 9, 4 (34) Leszek Bryniarski et al. Chronic total occlusion located in ostium of right coronary artery – retrograde approach

338

ThepatientwasadmittedtotheFirstDepartmentof

Cardiology, Interventional Electrocardiology and Hyper- tensionofJagiellonianUniversityMedicalCollegeinKra- kow14monthsafterthelastattemptofrecanalization.

Twoarterialaccesseswereobtained,themainonefrom

therightfemoralartery.Forvisualizationoftheproximal

segment of the RCA contralateral injections to the LCA

were performed. For this reason, for intubations of the

LCAaleftAmplatz4.07Fr(MedtronicVascular,USA)with

sideholeswasused.Theattemptofstreamliningtheoc- clusionbyanantegrademethodwithaFielderXTguide-

wire(AsahiIntecc,Japan)introducedonanOTW(“overthe

wire”)balloonwasunsuccessful.Becauseofunfavorable

morphology, small chance of success using the classical

antegrade method, and the presence of the perforator

connectingwiththedistalsegmentoftheRCA(Figure2),

theoperatordecidedtoapplytheretrogrademethod.

Fortheneedsoftheretrogrademethodtheoperator

usedanEBU4.07Frwithsideholes(MedtronicVascu- lar,USA)totheLCA.BymeansofaBMWguidewirewith

150cmlength(AbbottVascular,USA)aCorsairmicroca- theter(AsahiIntecc,Japan)wasintroducedintothesep- Fig. 1. Injection of contrast media to RCA. There

isocclusioninostiumofRCA,locateddirectlyto

conusartery

Fig. 3. Selective injection of contrast medium

throughCorsairmicrocathetershowedconnection

betweenseptalbranchandrightcoronaryartery

Fig. 2. Injectionofcontrastmediatoleftcoronary

artery.Arrowsshowseptalarteryconnectedwith

distalpartofRCA

Fig. 4. WhenCorsairmicrocatheterreachedosti- umofRCA,SionguidewirewaschangedforRG3

guidewire(330cm)

Postępy w Kardiologii Interwencyjnej 2013; 9, 4 (34)

Leszek Bryniarski et al. Chronic total occlusion located in ostium of right coronary artery – retrograde approach

339 talbranch.ThentheBMWwirewasreplacedbyaSion

wire (Asahi Intecc, Japan), which was put in the septal

branch. Connection with the distal portion of the RCA

was confirmed by selective contrast media injection to

amicrocatheter(Figure3).TheSionwasledtothedistal

segmentoftheRCAandpassedbackwardthroughthe

occlusiontothecatheterusedforcontralateralinjections

intheRCA(Figure4).

AftertheinsertionofaCorsairmicrocathetertothe

proximalpartoftheguidingcatheter,theSionwasre- placedforanAsahiRG3,withthelengthof330cm(Asahi

Intecc, Japan) – dedicated for externalization. The RG3

wasdrainedoutbyarterialaccessontheleftside.

Then, by the antegrade technique, a few sequential

balloon inflations by Maverick (Boston Scientific, USA)

1.5mm×20mmand2.5mm×20mm,toamaximumof

12atm,wereperformed.AftervisualizationaPromusEle- mentstent(BostonScientific,USA)3.0mm×38mm,18atm,

wasinserted(Figure5).Theresultwasevaluatedastheop- timaltreatmentwithTIMI3flow(Figure6).Theprocedure

timewas75min,500mlofcontrastmediawasused,fluo- ro-time27.3min,radiationdose3.4Gy.Thepost-procedural

coursewasuncomplicated.Thenextdayaftertheproce- durethepatientwasdischargedhomeingoodgeneralcon- dition,withtheinstructiontotakeoptimalpharmacother- apy.Ayearaftertheprocedurethepatientdoesnotreport

anginasymptomsandthetestexerciseisnegative.

Discussion

Chronic total occlusions still remain a challenge for

interventionalcardiologists.Advantagesoftheopeningof

chronicocclusioninpatientswhoseischemicmyocardial

areaisconfirmedaliveincludereliefofangina,reduction

of the incidence of arrhythmias, improved left ventricle

contractilityandlowermortality[1,2].Thepatencyofthe

rightcoronaryartery,especiallyinpatientswithreduced

ejectionfractionandchangesinothercoronaryarteries,

is significant. In patients undergoing unprotected left

mainpercutaneouscoronaryarteryangioplastyinwhich

therewasarightcoronaryarteryocclusionthe3-yearob- servation showed higher mortality from cardiac causes

compared with patients without significant changes in

theRCA(respectively30.0%vs.6.7%)[3].

Theoperatorexperience,knowledgeabouttheequip- ment,theabilitytousedifferentstreamliningtechniques

and proper patient selection can achieve effectiveness

of recanalization of about 90%. Ostial chronic total oc- clusion is considered exceptionally difficult to manage

andoftenrequiresmodificationoftechniques.Theret- rogrademethodisusuallythenextstepofmanagement

afterpreviousunsuccessfulrecanalizationbytheclassic

antegrade method. Although in the present case the

operators successfully intubated the right coronary ar- tery with a guiding catheter, morphology of the lesion

and presence of side branches reduced the chances of

openingantegradely;henceaftertheantegrademethod

thedecisionwastakentoperformaretrogradeone.Se- lectingtherightguidingcatheter,whichgivesadequate

support and is atraumatic for the artery, is one of the

crucial elements of effective recanalization. Due to the

good support for recanalization of chronic occlusion of

theRCA,aleftAmplatzcatheterisoftenused.Toreduce

Fig. 5. Stentimplantation–PromusElement3.0mm

×38mm–18atm

Fig. 6. Injection of contrast medium after stent

implantation.TIMI3flow

Postępy w Kardiologii Interwencyjnej 2013; 9, 4 (34) Leszek Bryniarski et al. Chronic total occlusion located in ostium of right coronary artery – retrograde approach

340

theriskofdissectionanddampingtheoperatorshould

apply the catheter version with side holes. In the case

ofabsenceofsideholesthiscanbedonewithaneedle.

Theuseofacatheterwithoutsideholesinthedistrict

hospitalatthefirstattemptofrecanalizationoftheRCA

causedventricularfibrillationwhichwasaconsequence

of blockage of blood flow in the artery. Another condi- tionforsuccessistochoosetherightguidewire.Inrecent

yearsthefirstchoiceguidewireistheFielderXT(Intecc

Asahi,Japan).Thisguidewirewith0.014”diameteriscov- eredwithhydrophilicpolymerfortheentirelengthand

hasaflexibletipattheend,characterizedbyexcellent

control. Diameter of the tip of the guide itself is only

0.009”.Thisguideisalsorecommendedintheretrograde

method. Due to the presence of collaterals connecting

theleftcoronaryarterywiththeRCA,itwaspossibleto

use retrograde techniques. This method has its origins

in the late eighties, but its growth and popularization

occurredintheyear2000andinlateryears[4].Afore- mentioned factors reduce the recanalization success

butareirrelevantwhenusingtheretrogradetechnique.

The only predictor of failure in the retrograde method

is unfavorable anatomy of collaterals. In this example

therewasavisibleseptalconnectionthatwasusedfor

achievingtheproximalsegmentoftheRCA.Injectionof

contrast media to the Corsair microcatheter confirmed

choosingtherightseptalbranch.Mostfrequentlyoper- ators applying the retrograde method use new guides

from Asahi Intecc such as Sion, providing an excellent

steering response when passing through collaterals.

The new guidewire used in this example was the RG3

guide.Thisisaguidededicatedtoexternalizationwith

a diameter of 0.010”, covered with a hydrophilic layer

whichensuresreductioninfrictionwhencarryingoutpro- cedures through curved coronaries and microcatheters.

Becauseoftheincreasedriskofrestenosisinachronical- lyclosedvessel,tooptimizetheresultofthetreatmentit

isrecommended,intheabsenceofcontraindicationsto

dualantiplatelettherapy,toimplantdrug-elutingstents.

Thisprovideslessfrequentoccurrenceofmajorcardiac

eventsandlessfrequentneedforrevascularization,and

reducesincidenceofrestenosisandreocclusionsascom- paredtometalstents[5].Inshort,tosucceedinthisdiffi- cultcaseofrecanalizationofchronicostialRCAocclusion,

thefollowingcontributed:appropriateselectionofguide

catheters,theabilitytoapplynewguidesandknowledge

ofCTOtechniques,includingretrogradetechniques.The

consensus of the Euro CTO Club for recanalization of

chronicocclusionsfromtheyear2012drawsattentionto

theneedforoperatorstohavepropertheoreticalknowl- edgeandpracticalexperienceinCTOrecanalization.An

independentoperatorcertificatedoesnotautomatically

translateintotheabilitytosuccessfullyperformrecanal- ization procedures of chronic occlusions. The minimum

frequencyofCTOrecanalizationperformedbyanoper-

ator to ensure adequate experience is 50 per year. For

thisreason,chronictotalcoronaryocclusionsshouldbe

performedbyalimitednumberofcentersandoperators

[4].Evaluatedin2011–2013,theaveragesuccessratein

CTO recanalization of operators belonging to the Euro

CTOClubis82.5%,whileinourdepartmentthisratiois

84.7%.InPoland,accordingtodatafromSISNPTK,the

percentageofsuccessfullytreatedCTOswas62.6%.Let

ushopethatthecontinuedrefinementoftheequipment

andthegrowingexperienceoftheoperatorswillfurther

improvetheeffectivenessofrecanalizationofchronicto- talcoronaryocclusion.

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