Controlled antegrade intimal tracking with subintimal balloon inflation as a novel bailout technique for chronic total occlusion after failed intravascular ultrasound-guided parallel wire technique
Yuta Imai1, Junji Yajima2, Fumitaka Hosaka1
1Department of Cardiology, Okamura Memorial Hospital, 293-1 Kakita, Shimizu-cho, Suntou-gun, Shizuoka, Japan 411-0904.
Insights
A novel technique successfully treated chronic total occlusion (CTO) percutaneous coronary intervention (PCI) when standard methods failed. Controlled antegrade intimal tracking with ballooning enabled wire crossing in challenging CTO cases.
Area of Science:
- Interventional Cardiology
- Vascular Medicine
- Medical Device Technology
Background:
- Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) frequently fails due to guidewire crossing difficulties.
- The intravascular ultrasound (IVUS)-guided parallel wire technique is a last resort for CTO PCI without collaterals, but can enlarge the subintimal space, leading to failure.
Observation:
- A case of left anterior descending artery CTO PCI without collaterals is presented where the IVUS-guided parallel wire technique failed due to an enlarged subintimal space.
- A second attempt utilized a novel approach: controlled antegrade intimal tracking with balloon inflation within the subintimal space.
Findings:
- This controlled antegrade intimal tracking technique successfully deflected a second guidewire, achieving antegrade wire crossing.
- The intervention ultimately succeeded despite the initial failure and enlarged subintimal space.
Implications:
- This technique offers a potential bailout strategy for complex CTO PCI cases where standard and parallel wire techniques have failed.
- It addresses the challenge of enlarged subintimal spaces, improving success rates in difficult CTO interventions.
Abstract:
Failure to cross with a guidewire is the most common reason for failure of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). In cases of CTO PCI with no interventional collaterals, an intravascular ultrasound (IVUS)-guided parallel wire technique is usually the last-resort procedure. Failure of this technique sometimes causes enlarged subintimal space, resulting in procedure failure. We present a successful second attempt at left anterior descending artery CTO PCI with no interventional collaterals. After IVUS-guided parallel wire technique failed with an enlarged subintimal space, successful antegrade wire crossing was achieved using controlled antegrade intimal tracking with balloon inflation in the subintimal space to deflect a second wire. This technique may be useful as a bailout strategy in otherwise-failed CTO PCI with an enlarged subintimal space.
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