Catheterization and Cardiovascular Interventions 83:929–932 (2014)
`
`The Utility of a GuidelinerTM Catheter in Retrograde
`Percutaneous Coronary Intervention of a Chronic Total
`Occlusion With Reverse CART—The “Capture”
`Technique
`
`Abdul M. Mozid,1* BMedSci, MRCP, MD, John R. Davies,1
`James C. Spratt,2
`FRCP, MD, FACC, FESC
`
`MRCP, PhD, and
`
`The hybrid approach to percutaneous treatment of chronic total occlusion (CTO) of
`coronary arteries requires both antegrade and retrograde skillsets. In the retrograde
`approach, wire externalization through the antegrade guide catheter often requires the
`use of a short donor guide catheter and a long (>150 cm) micro-catheter. Despite this
`there are occasions where the micro-catheter is unable to reach the anterograde guide
`catheter because of long collateral channels particularly when the retrograde limb
`involves a bypass graft. We report such a case where retrograde intervention was
`used to treat a right coronary artery (RCA) CTO in a patient with stable angina. The ret-
`rograde limb involved a saphenous vein graft to the native circumflex artery, which in
`turn provided collateral channels to the distal RCA. After performing reverse controlled
`anterograde and retrograde sub-intimal tracking (CART), the retrograde micro-catheter
`was only able to reach the mid RCA. To solve this, a GuidelinerTM catheter was passed
`on the antegrade wire and successfully advanced over and “captured” the retrograde
`micro-catheter. Wire externalization was then completed and the RCA was subse-
`quently stented with a good final angiographic result. This case illustrates a novel
`approach to completing wire externalization and provides a further indication for the
`role of the GuidelinerTM catheter in treating CTOs.
`VC 2013 Wiley Periodicals, Inc.
`
`Key words: chronic total occlusion; retrograde PCI; reverse CART
`
`INTRODUCTION
`
`Chronic total occlusion (CTO) of a coronary artery
`is identified in 15–30% of patients undergoing diagnos-
`tic angiography [1,2]. This complex lesion subset
`remains a strong predictor for referral for coronary ar-
`tery bypass surgery (CABG) [2]. However, in patients
`with single vessel disease or those with multi-vessel
`disease and low/intermediate SYNTAX scores, percuta-
`neous coronary intervention (PCI) should be considered
`[3]. Successful re-canalization of a CTO is associated
`with improved cardiac function and clinical outcome
`[4]. Historically, an antegrade only approach to CTO
`re-canalization is associated with a success rate of 60–
`70% [4]. However, in recent years there have been sig-
`nificant developments in techniques and equipment so
`that there now exists multiple intervention strategies. A
`“hybrid” approach to CTO intervention has been pro-
`posed with a treatment algorithm based upon initial
`angiographic evaluation of the coronary anatomy and
`
`VC 2013 Wiley Periodicals, Inc.
`
`prompt progression to an alternative strategy in case of
`failure [5].
`Retrograde PCI has rapidly evolved since its first
`description [6] and has enabled improved procedure
`
`1The Essex Cardiothoracic Centre, Basildon, Essex SS16
`5NL, United Kingdom
`2Forth Valley Royal Hospital, Larbert, FK5 4WR, United
`Kingdom
`
`Conflict of interest: Nothing to report.
`
`*Correspondence to: Dr. Abdul M. Mozid, The Essex Cardiothora-
`cic Centre, Basildon, Essex SS16 5NL, UK. E-mail: ammozid@
`hotmail.com
`
`Received 25 June 2013; Revision accepted 12 September 2013
`
`DOI: 10.1002/ccd.25205
`Published online 2 October 2013 in Wiley Online Library
`(wileyonlinelibrary.com)
`
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`Mozid et al.
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`Fig. 1. Top panel: Dual contrast injections demonstrating (a) occluded native RCA with am-
`biguous proximal cap and long occlusion length and (b) retrograde collaterals from distal Cir-
`cumflex artery to distal RCA. Bottom panel: (c) sub-intimal tracking (knuckle technique) of
`both antegrade and retrograde wires with Corsair micro-catheter support; (d) antegrade sub-
`intimal space enlarged with a 2.5 mm 3 15 mm compliant balloon inflation (marked with
`arrow).
`
`snared in the aorta). In this case report, we describe an
`alternative approach to wire externalization when the
`retrograde micro-catheter is unable to reach the ante-
`grade guide catheter.
`
`success rate [7]. Reverse controlled anterograde and
`retrograde sub-intimal tracking (CART) involves sub-
`intimal entry of both antegrade and retrograde wires,
`with subsequent balloon expansion permitting commu-
`nication through the previously occluded section [6]. A
`key step of the retrograde approach is wire externaliza-
`tion through the antegrade guide catheter. To enable
`this, a short (90 cm) retrograde (or donor) guide cathe-
`ter may be required as well as a long micro-catheter
`(such as the 150 cm Corsair, Asahi Intecc.). Wire
`externalization usually requires the retrograde micro-
`catheter to enter the antegrade guide so that the wire
`can be exchanged to a long guidewire. However, there
`maybe occasions where the micro-catheter is unable to
`reach the guide catheter and a long wire has to be used
`to wire the antegrade guide (either directly or by being
`Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
`Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
`
`CASE REPORT
`
`A 73-year-old man, with recurrence of angina, was
`admitted to our tertiary center for elective PCI to a
`chronically occluded right coronary artery (RCA). He
`had prior history of CABG surgery with left internal
`mammary artery (LIMA) to left anterior descending
`(LAD) artery and saphenous vein grafts (SVG) to RCA
`and circumflex coronary arteries. Diagnostic angiogra-
`phy had showed a recent occlusion of the SVG to the
`RCA and a cardiac MRI scan demonstrated an induci-
`ble perfusion defect in the RCA territory.
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`Utility of GuidelinerTM Catheter in Retrograde PCI
`
`931
`
`(a) The retrograde wire and Corsair micro-catheter advanced into same plane as the
`Fig. 2.
`antegrade wire at the mid-RCA level; (b) GuidelinerTM catheter advanced antegradely to cap-
`ture the retrograde Corsair micro-catheter (tip of Corsair catheter marked with * and
`GuidelinerTM tip marked with arrow).
`
`The procedure was carried out via bilateral femoral
`artery access with 8 Fr 45 cm sheaths. The RCA was
`intubated with a standard length (110 cm) 8 Fr AR2
`guide catheter and the SVG to circumflex was intuba-
`ted with a short (90 cm) AL1 guide.
`long
`Dual contrast
`injections confirmed proximal
`occlusion of the native RCA (Fig. 1a) and good retro-
`grade interventional collateral channels from the native
`circumflex artery (Fig. 1b).
`Due to ambiguity of the proximal cap and the long
`occlusion length (20 mm), a primary retrograde
`approach was chosen using the SVG to circumflex and
`collateral epicardial channels from the native circum-
`flex artery.
`A Sion wire (Asahi Intecc) and 150 cm Corsair
`micro-catheter (Asahi Intecc.) were advanced from the
`epicardial collateral channel to the distal RCA. The ret-
`rograde wire was exchanged to a Pilot 200 (Abbott
`Vascular), which was then “knuckled” (by forming a
`small loop and dissecting the sub-intimal/sub-adventi-
`tial plane) across the distal occlusion with Corsair cath-
`eter support (Fig. 1c).
`A Fielder XT wire (Asahi Intecc.) was “knuckled”
`antegradely at the proximal occlusion site into the sub-
`intimal space with a 135 cm Corsair micro-catheter
`support (Fig. 1c). The antegrade and retrograde corsair
`catheters were advanced so that they were overlapping,
`which was confirmed in separate orthogonal planes.
`The antegrade sub-intimal space was enlarged by bal-
`loon inflation (2.5 mm  15 mm) (marked with arrow
`in Fig. 1d). The retrograde wire and Corsair catheter
`were then successfully advanced into same plane as the
`antegrade wire at the mid-RCA level (Fig. 2a).
`However,
`the long length of the retrograde limb
`from the SVG meant
`that
`the 150 cm Corsair was
`
`Fig. 3. Final angiographic result following implantation of
`three drug eluting stents.
`
`unable to reach the antegrade guide catheter despite
`the short (90 cm) contralateral guide catheter. To solve
`this issue, a 6 Fr GuidelinerTM catheter (Vascular Solu-
`tions) was advanced antegradely and was able to suc-
`cessfully advance over and capture the retrograde
`Corsair catheter (Fig. 2b). The retrograde Pilot 200
`was then exchanged for a 330 cm RG3 wire (Asahi
`Intecc.), which was then externalized. PCI was then
`completed antegradely on the RG3 wire and the vessel
`was stented from distal to ostium with three overlap-
`ping everolimus drug-eluting stents with a good final
`angiographic result (Fig. 3).
`Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
`Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
`
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`DISCUSSION
`
`Retrograde PCI with retrograde dissection re-entry
`techniques has improved the success of recanalization
`with of CTOs. The advent of
`the Corsair
`(Asahi
`Intecc.) channel dilator has further simplified collateral
`crossing [8]. A long 150 cm Corsair catheter is usually
`able to reach the antegrade guide catheter thereby ena-
`bling wire exchange to a long wire (e.g., 330 cm RG3
`(Asahi Intecc.) or 335 cm ViperWire (Cardiovascular
`Systems Inc.)) and therefore wire externalization. How-
`ever, in cases of long tortuous retrograde channels, par-
`ticularly when also involving a graft,
`the Corsair
`catheter may be unable to reach the antegrade guide
`catheter. In this situation, potential solutions include
`exchanging for a long wire and using this to enter the
`antegrade catheter directly—although this can be diffi-
`cult, particularly if the wire has to negotiate long seg-
`ments of diseased artery. The long wire can also be
`snared in the aorta using standard snare devices deliv-
`ered through the antegrade guide catheter. An alterna-
`tive is to exchange the Corsair catheter for an over-
`the-wire or long rapid exchange balloon and perform
`retrograde angioplasty to allow passage of an antegrade
`wire.
`We have demonstrated in our case report a third
`option utilizing the GuidelinerTM (Vascular Solutions)
`mother-and-child catheter. This rapid-exchange device
`consists of a 20 cm soft flexible tube connected to a
`stainless-steel rod and can be used to deeply intubate a
`coronary artery to provide additional back-up support.
`This ability to extend the guide deep into the artery
`offers the solution of connecting the retrograde micro-
`catheter to the antegrade guide catheter. Providing the
`retrograde Corsair catheter is in the same tissue plane
`as the antegrade wire, the GuidelinerTM catheter can be
`advanced over and “capture” the Corsair catheter. This
`technique may provide a simpler method for complet-
`ing wire externalization than the previous options.
`Other advantages of the GuidelinerTM system include
`circumventing the need for the retrograde wire to nego-
`tiate long sections of diseased artery; the ability to pro-
`vide a scaffold for the artery by preventing collapse of
`space created by antegrade balloon inflation; providing
`
`extra support to aid with stent delivery and reducing
`the need for contrast.
`
`CONCLUSIONS
`
`Retrograde access is an important skill-set required
`for CTO PCI. When the retrograde limb involves a
`graft and/or tortuous collateral channels the retrograde
`Corsair catheter maybe too short to reach the antegrade
`guide catheter even with the use of a shortened donor
`guide. In this situation, advancing an antegrade Guide-
`linerTM over the retrograde Corsair micro-catheter, the
`“capture technique,” facilitates wire externalization.
`
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`Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.
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