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Successful bypass restenting across the struts of an occluded subintimal stent in chronic total occlusion using a
Hidefumi Ohya1, Eisho Kyo, Osamu Katoh
1Division of Cardiology, Kusatsu Heart Center, Shiga, Japan.
Insights
Subintimal angioplasty for coronary total occlusions (CTO) can lead to in-stent restenosis. Bypass restenting using a retrograde approach successfully restored blood flow in two challenging cases.
Area of Science:
- Interventional Cardiology
- Vascular Medicine
- Cardiovascular Interventions
Background:
- Subintimal angioplasty is a bailout strategy for percutaneous coronary intervention (PCI) in chronic total occlusions (CTOs).
- Long-term outcomes and re-entry challenges limit subintimal angioplasty.
- Occlusive in-stent restenosis within a subintimal stent presents a complex clinical scenario.
Observation:
- Two cases of occlusive in-stent restenosis in the right coronary artery (RCA) following subintimal stent placement for CTO are presented.
- The restenosis occurred within a stent previously implanted in the subintimal space.
Findings:
- Successful treatment was achieved using bypass restenting across the struts of the occluded subintimal stent.
- A retrograde approach enabled wire crossing through the occluded segment and re-entry into the stent.
- The reverse CART technique followed by multiple restents restored antegrade flow, confirmed by follow-up angiography.
Implications:
- This retrograde bypass restenting technique offers a viable solution for managing complex in-stent restenosis after subintimal angioplasty.
- It addresses the limitations of uncertain re-entry points associated with subintimal techniques.
- Demonstrates a novel strategy to restore patency in previously treated CTOs with challenging restenosis.
Abstract:
Recently, subintimal angioplasty has been introduced as a bailout strategy to improve the success rate of PCI for vessels with CTO. However, the long-term outcome of subintimal angioplasty has not been determined, and a limitation of subintimal angioplasty is the uncertainty in making the re-entry point. We report two cases, where occlusive in-stent restenosis occurred in a stent implanted in the subintimal space of the RCA that had CTO. These two cases were successfully treated with bypass restenting across the struts of an occluded subintimal stent using a retrograde approach. A retrograde wire crossed the occluded segment through the lumen along the outside of the stent and reentered the inside of the stent across the stent struts. The reverse CART technique followed by multiple restenting across the stent struts restored antegrade flow. Follow-up angiography demonstrated the patency of the RCA.
