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Transradial retrograde approach rescuing iatrogenic long spiral dissection during chronic total occlusion
Sayed M Abdou1, Hon Kan Yip, Chiung-Jen Wu
1Cardiology Department, National Heart Institute, Cairo, Egypt.
Insights
A retrograde approach rescued a complex percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) after antegrade wiring caused dissection. This technique offers a valuable rescue strategy for challenging CTO cases.
Area of Science:
- Interventional Cardiology
- Vascular Biology
- Medical Device Technology
Background:
- Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) remains a significant challenge in interventional cardiology.
- The retrograde approach, utilizing collateral channels, has emerged as a promising strategy to improve PCI success rates in CTO lesions.
Observation:
- During transradial PCI for right coronary artery CTO, antegrade wiring resulted in extensive spiral dissection from the ostium to the mid-segment.
- Initial antegrade attempts to re-enter the true lumen were unsuccessful, necessitating an alternative strategy.
Findings:
- An ad-hoc retrograde approach via septal collaterals from the left anterior descending artery was successfully employed to rescue the dissected vessel.
- Intravascular ultrasound (IVUS) guided successful antegrade wiring into the true lumen, revealing intramural hematoma.
- Bailout stenting effectively sealed dissection entry/exit sites and covered the intramural hematoma, leading to successful recanalization.
Implications:
- This case underscores the critical role of the retrograde approach as a rescue strategy in complex CTO-PCI when antegrade techniques fail.
- Intravascular ultrasound (IVUS) is demonstrated as an invaluable tool for confirming true lumen navigation and guiding complex stenting procedures in CTO interventions.
- The successful application of the retrograde approach highlights its potential to enhance procedural success rates in challenging CTO cases.
Abstract:
Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is one of the greatest challenges in coronary interventions. A retrograde approach via the collateral channel has been recently proposed to improve the success rate of PCI in CTO lesions of the coronary arteries. We describe an accidental complication encountered during transradial PCI to recanalize right coronary artery CTO in a patient with unstable angina. A long spiral dissection has been created by antegrade wiring and extended from the ostium all the way down to mid RCA segment. Subsequent attempts with antegrade wiring into the true lumen were unsuccessful. Ad-hoc retrograde recanalization has been employed to rescue the vessel via septal collateral from left anterior descending artery. Retrograde wiring and dilatation were performed followed by successful antegrade wiring into the true lumen under IVUS guidance, which revealed significant intramural hematoma extending distally to the posterolateral branch. Bailout stenting was achieved with sealing of the multiple entry and exit sites created by the spiral dissection and complete coverage of the intramural hematoma. This report highlights the role of the retrograde approach as a rescue option in the setting of complicated antegrade approach and to improve the success rate of CTO-PCI. Moreover, IVUS was a valuable tool to confirm the true lumen course of the successful wire and to guide the stenting procedure.
