Electrocautery-Facilitated Crossing (ECFC) of Chronic Total Occlusions

The use of electrocautery (EC)-facilitated re-entry in an aorto-ostial chronic total occlusion (CTO) of the right coronary artery (RCA) was first described in 2016. Since then, it has been utilized sporadically, but little is reported about the use of EC in lesion crossing during CTO percutaneous coronary intervention (PCI). The objective of this study is to describe the efficacy of EC-facilitated crossing (ECFC) of CTOs.

We report a case series of ECFC of CTOs where standard techniques are either not suitable or ineffective. We utilized stiff, high tip-load, and tapered guidewires energized with EC to facilitate wire crossing of wire-uncrossable CTOs.

A total of 293 CTO-PCIs were performed at our institution between October 16, 2016 and October 30, 2018 and ECFC was attempted in 6 cases (2%); 5 cases were retrograde and 1 case was both antegrade and retrograde. All 6 cases were classified as very difficult by the J-CTO score of ≥3. ECFC was performed in 2 aorto-ostial lesions, 3 lesions at the major bifurcation, and 1 lesion in the proximal obtuse marginal. The successful crossing of the target lesion was achieved using ECFC in 5 cases (83%). We were unable to cross 1 lesion of severe in-stent restenosis with stent fracture at the distal RCA bifurcation. Despite attempting ECFC, both antegrade and retrograde crossing remained unsuccessful. There were no ECFC-related complications.

The use of energized stiff guidewires to perform ECFC can be of great value for CTO lesions when standard CTO techniques fail. ECFC should only be performed with caution by experienced and high-volume operators to avoid complications.