European Heart Journal - Case Reports
`doi:10.1093/ehjcr/yty036
`
`CASE SERIES
`Coronary heart disease
`
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`Zero contrast retrograde chronic total
`occlusions percutaneous coronary
`intervention: a case series
`
`Raja Hatem1,2,3, Matthew T. Finn1,2, Robert F. Riley4, Moses Mathur4,
`William L. Lombardi4, Ziad A. Ali1,2†, and Dimitri Karmpaliotis1,2*†
`
`1Columbia University, 161 Fort Washington Avenue, 6th Floor, New York, NY 10032, USA; 2Cardiovascular Research Foundation, 1700 Broadway, 8th Floor, New York, NY
`10019, USA; 3Hoˆpital du Sacre´-Coeur de Montre´al, Universite´ de Montre´al, 5400 Boul Gouin O, Montre´al, QC H4J 1C5, Canada; and 4Department of Cardiology, University of
`Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195, USA
`
`Received 30 November 2017; accepted 28 March 2018; online publish-ahead-of-print 2 April 2018
`
`Introduction
`
`Percutaneous coronary intervention (PCI) in patients with advanced chronic kidney disease (CKD) is associated
`with a high risk of contrast-induced nephropathy and resulting progression of CKD to need for renal replacement
`therapy. Chronic total occlusions (CTO) PCI is increasingly utilized in the treatment of refractory stable angina and
`ischaemic heart failure. Recent studies have described the feasibility of ‘minimal’ or ‘zero’ contrast PCI by employing
`intravascular imaging and intra-coronary physiology to guide successful stent implantation with resolution of ischae-
`mia. We extended these techniques to CTO lesions via the retrograde approach.
`...................................................................................................................................................................................................
`Case
`Two patients with estimated glomerular filtration rate <_15 mL/min who presented with angina symptoms and had
`presentation
`subsequent positive stress tests were referred for CTO-PCI. The patients had diagnostic angiography with minimal
`contrast. After a recovery period, the patients underwent successful retrograde zero contrast CTO-PCI with the
`use of adjunctive intravascular ultrasound imaging.
`...................................................................................................................................................................................................
`Discussion
`The described reports are the first two successful attempts at zero contrast retrograde procedures and demon-
`strate the feasibility of imaging and physiology-guided retrograde PCI without contrast administration in two pa-
`tients with significant coronary artery disease requiring intervention. When indicated, zero contrast PCI offers the
`ability to treat obstructive coronary disease without worsening renal function in patients with severe CKD.
`
`䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏
`
`Keywords
`
`Chronic occlusion • Percutaneous coronary intervention • Retrograde • Chronic kidney disease
`• Contrast-induced nephropathy • Case series
`
`Learning points
`• These cases describe a first-in-man technique utilizing zero contrast to perform retrograde chronic total occlusions percutaneous coronary
`intervention (PCI) to treat patients with concomitant coronary artery disease and chronic kidney disease (CKD).
`• The procedure utilizes prior angiographic films together with intravascular imaging and invasive physiological testing to enable zero contrast
`retrograde lesion crossing and stenting.
`• Minimal or zero contrast PCI, when indicated, offers the opportunity to improve overall outcomes related to ischaemic heart disease with-
`out risking worsening renal function or dialysis in patients with CKD.
`
`* Corresponding author. Tel: (212) 305-7060, Fax 212-305-0676, Email: dk2787@cumc.columbia.edu. This case report was reviewed by Joshua Chai and Dejan Milasinovic.
`† These authors contributed equally to this work.
`VC The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Cardiology.
`This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/),
`which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
`journals.permissions@oup.com
`
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`2
`
`Introduction
`
`Percutaneous coronary intervention (PCI) in patients with advanced
`chronic kidney disease (CKD) is associated with a high risk of con-
`trast-induced nephropathy (CIN), risking progression of CKD and
`need for renal replacement therapy.1,2 We have recently described
`the feasibility and safety of imaging and physiology-guided PCI with-
`out contrast utilization by employing intravascular imaging and intra-
`coronary physiology to guide successful stent implantation.3 Chronic
`total occlusions (CTO) PCI is an increasingly utilized approach in the
`treatment of refractory stable angina and ischaemic heart failure with
`data demonstrating improved clinical and functional outcomes in se-
`lected patients.4 We describe the feasibility and safety of imaging and
`physiology-guided PCI without contrast administration in two cases
`
`R. Hatem et al.
`
`...........................................
`
`using the retrograde approach, illustrating a successful method to
`treat this extreme risk subset of patients.
`
`Case 1: clinical background
`A 54-year-old man with a history of Type I diabetes mellitus, hyper-
`tension, and CKD Stage IV with an estimated glomerular filtration
`rate (eGFR) of 15 mg/min/1.73 m2 (normal: >_60 mg/min/1.73 m2)
`presented for diagnostic angiography after a non-invasive nuclear
`scan, done for exertional chest pain, identified a moderate size and
`moderate severity ischaemic defect in the basal half of the inferior
`and inferolateral walls. Diagnostic angiography (20 mL contrast),
`demonstrated a right coronary artery (RCA) CTO (Figure 1A and B;
`Supplementary material online, Videos S1 and S2 Case S1).
`
`Figure 1 (A and B) Diagnostic angiography performed 1-month prior to chronic total occlusions percutaneous coronary intervention demonstrat-
`ing a right coronary artery chronic total occlusions and left anterior descending distal and septal collaterals to the right coronary (arrow).
`(C) Retrograde wiring via septal collateral. (D) Positioning of microcatheters at the proximal and distal chronic total occlusions caps to prepare for re-
`verse controlled antegrade or retrograde subintimal tracking. (E) GuideLiner assisted reverse controlled antegrade or retrograde subintimal tracking
`(arrow). (F) Retrograde wire has been externalized and the patient is undergoing pre-stenting angioplasty for lesion preparation. (G) Intravascular
`ultrasound image of the pre-stenting angioplasty demonstrating luminal narrowing. (H and I) Distal and proximal intravascular ultrasound images
`(respectively) after stenting.
`
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`Zero contrast retrograde CTO-PCI
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`3
`
`Case 1: procedure description
`The patient returned, after failing to respond to medical therapy,
`for staged CTO-PCI of the RCA 1 month after the initial diagnos-
`tic angiogram. Prior to the procedure, previous angiographic films
`were uploaded to the monitors as a guide for coronary wiring.
`Using those images as reference, a polymer jacketed hydrophilic
`wire (Fielder FC, Asahi Intecc, Japan) was successfully manipulated
`through a septal collateral up to the distal cap of the CTO (Figure
`1C; Supplementary material online, Video S3 Case S1). Once the
`antegrade and retrograde base of operations were confirmed in
`
`...............................
`
`reverse
`a
`angiographic images,
`comparison to the prior
`GuideLiner (Teleflex Vascular Solutions, Minneapolis, MN, USA)
`assisted controlled antegrade or retrograde subintimal tracking
`(RCART) technique was used to cross the CTO with an Asahi
`Gaia Third wire (Figure 1D; Supplementary material online, Video
`S4 Case S1). After externalization, antegrade IVUS guided angio-
`plasty to the RCA was performed with Doppler colour confirm-
`ation of outflow (Figure 1E–I, Supplementary material online, Video
`S5 Case S1). The procedure was completed with 0 mL of contrast,
`a total fluoro time of 38.9 min, and a radiation dosage of 0.491 Gy.
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`Figure 2 (A) Prior angiographic images demonstrating a proximal left anterior descending chronic total occlusions (arrow). (B) Angiography of the
`saphenous vein graft to the left anterior descending artery with a high-grade ostial saphenous vein graft stenosis (circle) and retrograde filling of
`the left anterior descending until distal chronic total occlusions cap (arrow). (C) 1, Wire in distal left anterior descending artery from the saphenous
`vein graft to mid-left anterior descending using the retrograde guide; 2, antegrade wire in the left anterior descending artery septal using the
`antegrade guide; 3, antegrade wire in the first diagonal; and 4, wire at the diseased second diagonal next to the proximal chronic total occlusions cap.
`(D) 1, Wire in distal left anterior descending artery from the saphenous vein graft using to the mid-left anterior descending retrograde guide; 2,
`antegrade wire in the left anterior descending artery septal; 3, antegrade wire in the first diagonal; 4, wire at the diseased second diagonal next to the
`proximal chronic total occlusions cap; and 5, Turnpike with pilot 200-wire aimed retrograde at distal chronic total occlusions cap. (E) Chronic total
`occlusions lesion crossed using reverse controlled antegrade or retrograde subintimal tracking technique with entry of the retrograde wire into the
`antegrade GuideLiner for externalization. (F) After utilization of the Twin Pass catheter to access the distal left anterior descending from antegrade, a
`balloon is inflated (arrow) dilating the chronic total occlusions lesion. (G) Intravascular ultrasound of the left anterior descending artery after balloon-
`ing and prior to stenting demonstrating luminal narrowing. (H and I) Distal and proximal intravascular ultrasound images (respectively) after stenting.
`
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`4
`
`R. Hatem et al.
`
`The patient was discharged the following day following a normal
`transthoracic echocardiogram (TTE). No renal replacement
`therapy was required prior to during the inpatient hospital stay.
`On 6 month follow-up,
`the patient experienced signficant
`improvement in their chest pain symptoms without need for
`hospitalization or initiation of renal replacement therapy.
`
`Case 2: clinical background
`A 73-year-old man with a past history of poorly controlled diabetes
`mellitus Type II, Stage V CKD with an eGFR of 10 mg/min/1.73 m2
`(normal: >_60 mg/min/1.73 m2) ischaemic cardiomyopathy (ejection
`fraction of 40%), moderate aortic stenosis and two separate coron-
`ary artery bypass grafting surgeries with saphenous vein grafts (SVGs)
`to the mid-left anterior descending (LAD) artery (previous LIMA
`to LAD was atretic), first obtuse marginal and right posterior
`descending artery presented with a NSTEMI. The patient previ-
`ously received two layers of drug eluting stents to his SVG-LAD
`graft and initial angiography showed that he had developed recur-
`rent ostial in-stent restenosis (Figure 2A and B, Supplementary ma-
`terial online, Videos S1 and S2 Case S2). He was discharged on
`optimal medical therapy with subsequent stress testing showing a
`large area of moderate ischaemia in the LAD territory. Given his
`high-risk stress test findings and in preparation for renal trans-
`plantation evaluation, a heart team decision was made to proceed
`with percutaneous revascularization of his native LAD approxi-
`mately 3 months after his NSTEMI.
`
`Case 2: procedure description
`Angiographic films from the patient’s initial angiography were up-
`loaded to the monitors to guide contrast-free wiring. First, the distal
`LAD was wired via the SVG. Then, three anterograde wires were
`placed down the septal perforator, the first diagonal artery and the
`diseased second diagonal adjacent to the proximal CTO cap. These
`wire positions allowed improved contrast-free visualization of the
`proximal cap location (Figure 2C and D; Supplementary material on-
`line, Video S3 Case S2). A 7 Fr Trapliner (Teleflex Vascular Solutions,
`Minneapolis, MN, USA), Turnpike microcatheter, and Pilot 200
`(Abbott, Abbott Park, IL, USA) were advanced retrograde from the
`SVG and aimed at the distal CTO cap. Once the antegrade and retro-
`grade base of operations were confirmed in comparison to the previ-
`ous angiogram, a GuideLiner assisted Reverse CART technique was
`used to successfully cross the CTO using an Asahi Confianza Pro 12
`wire (Figure 2E, Supplementary material online, Video S4 Case S2).
`After externalization, a Twin Pass catheter (Teleflex Vascular
`Solutions, Minneapolis, MN, USA) was used over the externalized
`wire to help wire the distal LAD from the antegrade guide (Figure 2F,
`Supplementary material online, Video S5 Case S2). IVUS guided PCI
`was then performed (Figure 2G–I, Supplementary material online,
`Video S6 Case S2) and resolution of ischaemia in the LAD was con-
`firmed with post-PCI FFR (0.94) utilizing a balloon occlusion of the
`SVG to LAD to mitigate competitive flow. The procedure was com-
`pleted with 0 mL of contrast, a fluoroscopic time of 95 min and
`3.5 Gy radiation dosage. The patient was discharged on postoperative
`Day 1 with no immediate or follow-up complications. The patient re-
`mained off dialysis at 3 months follow-up and was approved for listing
`for renal transplantation.
`
`........
`
`....................................................................................................................................................................
`
`Timeline
`
`Index Procedure
`
`Case 1
`.................................................................................................
`1 month prior to index
`Exertional Angina, Ischaemia on Nuclear
`procedure
`Stress Test, baseline eGFR 15 ml/min
`Diagnostic Catheterization with 20 ml/min
`Zero Contrast Retrograde CTO PCI -
`Successful
`Significant improvement in angina, no hos-
`6 months post-index
`procedure
`pitalization, no haemodialysis
`.................................................................................................
`Case 2
`.................................................................................................
`3 months prior to index
`Chest pain and NSTEMI, diagnostic cathe-
`procedure
`rization, medical management of CAD
`1 month prior to index
`Renal transplant evaluation, high-risk
`procedure
`stress test
`Index Procedure
`Zero Contrast Retrograde CTO PCI -
`Successful
`Approved for renal transplant, no
`haemodialysis
`
`3 months post-index
`procedure
`
`Discussion
`
`Percutaneous coronary intervention of CTO represents the most
`technically challenging procedure in contemporary interventional
`cardiology. Patients with a CTO generally have increased cardiac risk
`profiles compared with those without CTO. Among this high-risk pa-
`tient subset, patients with advanced CKD are at an even greater risk
`of adverse events, as CIN is directly correlated with higher rates of
`adverse clinical events and progression to end stage renal disease.1
`Performing minimal or zero contrast PCI, when indicated, offers the
`opportunity to improve overall outcomes related to ischaemic heart
`disease without risking worsening renal function or dialysis in this ex-
`treme risk group of patients.3 The present cases demonstrate, for the
`first time, the feasibility of retrograde complex CTO-PCI without
`contrast utilization.
`Careful study of the prior diagnostic angiogram is fundamental to
`successful wire navigation without using contrast. Significant expert-
`ise with IVUS and coronary physiological technology is also quintes-
`sential and only highly trained IVUS interpreters operators should
`attempt these procedures. Use of physiological measurements such
`as FFR or flow-based imaging can aid confirmation of the restoration
`of antegrade flow in the treated vessel at the end of the procedure.
`A high level of preparedness and expertise in managing coronary
`complications is paramount for such procedures. The threshold for
`using contrast in the event of a suspected complication is low and
`close monitoring of these patients during the peri-procedural period
`with pre- and post-TTE is necessary to evaluate for pericardial effu-
`sion from non-visualized coronary perforations during the procedure.
`While the described procedures should currently be limited to ex-
`pert CTO operators only, we feel that this case series has broader
`implications. First, taken together with recent publications on minimal
`contrast PCI, one can infer that in most cases operators are capable
`
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`Zero contrast retrograde CTO-PCI
`
`5
`
`of using less contrast than the current standard placing some patients
`with baseline renal dysfunction at additional avoidable risk.
`Secondly, these cases demonstrate that even the most complex
`PCI is possible with zero/minimal contrast. While, we describe two
`cases with zero contrast using planned RCART CTO approaches, it
`is possible that retrograde ‘true-to-true’ wiring could be performed
`with zero contrast once the coronary tree had been mapped using
`antegrade and retrograde wires. Other CTO approaches may not
`permit contrast-free wiring; however, may be successfully completed
`with minimal contrast use.
`imaging and physiology-
`In conclusion, we describe successful
`guided CTO-PCI without contrast utilization. Such techniques may
`be adopted in centres with expertise in complex PCI and use of intra-
`vascular imaging and physiology to provide revascularization without
`the major complications of CIN in these extremely high-risk group of
`patients.
`
`Supplementary material
`
`Supplementary material is available at European Heart Journal – Case
`Reports online.
`
`Funding
`National Institutes of Health (T32HL007854 to M.T.F.).
`
`.............................................................................
`
`Consent: The author/s confirm that written consent for submission and
`publication of this case report including image(s) and associated text has
`been obtained from the patient in line with COPE guidance.
`
`Conflict of interest: D.K. is speaker honoraria from Abbot Vascular,
`Boston Scientific, Asahi, and Medtronic. Z.A.A. grants
`from St
`Jude Medical and Cardiovascular Systems and personal fees from St Jude
`Medical, Acist Medical outside the submitted work. W.L.L. dis-
`closes equity with Bridgepoint Medical. R.F.R. received speaker honoraria
`from Abiomed and Spectranetics. All other authors have nothing to
`disclose.
`
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