Subintimal dissection/reentry strategies in coronary chronic total occlusion interventions

Abstract

Subintimal dissection/reentry techniques are increasingly being used for crossing coronary chronic total occlusions both antegradely (using a knucle wire or the Bridgepoint system) or retrogradely (using the controlled antegrade and retrograde tracking and dissection, and reverse controlled antegrade and retrograde tracking and dissection technique). Subintimal dissection/reentry techniques can increase procedural success rates, but their subsequent clinical outcomes are poorly studied, and they appear to be associated with high rates of in-stent restenosis and repeat target lesion revascularization. In the present review, we describe in detail the chronic total occlusions subintimal dissection/reentry techniques, clarify the related terminology and summarize the published studies in this area and the current gaps of knowledge.

Figures

Figure 1

Classification of the chronic total occlusion dissection/re-entry strategies. CTO, chronic total occlusion; STAR, Subintimal Tracking And Re-entry; LAST, Limited Antegrade Subintimal Tracking.

Figure 2

(provided by Bridgepoint Medical, Minneapolis, Minnesota), Panel A. Illustration of the CrossBoss Catheter, which is an over-the-wire device (0.014″ guidewire compatible) with a 1mm rounded tip, a coiled shaft and a moveable proximal torque device that releases under high torque to prevent product damage. Panel B. Illustration of the Stingray CTO re-Entry System, with its two components: (a) the Stingray CTO orienting balloon catheter and (b) the Stingray CTO re-entry guidewire. The Stingray balloon has two side exit ports (arrows) located on diametrically opposite balloon surfaces immediately proximal to two radiopaque markers (yellow bands on Figure). The flat shape of the Stingray balloon orients one exit port automatically toward the vessel true lumen upon low pressure inflation (2-4 atm). The Stingray guidewire has a 0.0035 inch distal taper (image insert) allowing it to re-enter the true vessel lumen through the exit port of the Stingray balloon after subintimal passage of the guidewire. Panel C and D. Illustration of the CrossBoss catheter use in an animal (panel C) or human (panel D) occlusion specimens.

Figure 3

Use of the CrossBoss catheter (Bridgepoint Medical), knuckle wire, and Stingray balloon and wire (Bridgepoint Medical) for subintimal crossing. Chronic total occlusion of the proximal right coronary artery (arrow, panel A) with filling of the right posterior descending artery via collaterals from the left anterior descending artery (arrow, panel B). Using a CrossBoss catheter (Bridgepoint Medical) and a knuckle wire (arrow, panel C) the lesion was crossed subintimally. Using the Stingray balloon (arrows, panel D) and wire (Bridgepoint Medical) the wire was advanced into the distal right coronary artery, as confirmed by contralateral injection (panel D), with an excellent angiographic result after stent implantation (panel E).

Figure 4

Contrast-guided Subintimal Tracking and Re-entry (STAR) technique. Chronic total occlusion of the proximal right coronary artery (arrow, panel A), treated with injection of contrast via a microcatheter resulting in subintimal contrast entry (arrows panel B) into the distal true lumen, with successful recanalization after stenting (panel C).

Figure 5

Use of the Limited Antegrade Subintimal Tracking (LAST) technique. Chronic total occlusion of the ramus intermedius branch (arrows, panel A). Crossing attempts with a Confianza Pro 12 wire (Abbott Vascular) failed (arrow, panel B). A Fielder XT wire (Asahi Intecc) remained intraluminal but could not cross the occlusion (arrow, panel C). The Fielder XT wire was advanced until a knuckle formed at its tip (arrow, panel D) that crossed the CTO into the subintimal space. A Confianza Pro 12 guidewire was used to re-enter into the distal true lumen (arrow, panel E), with an excellent final angiographic result post stenting (panel F).

Figure 6

Illustration of re-entry techniques utilized during retrograde CTO interventions. Panel 1. Step-by-step illustration of the controlled antegrade and retrograde tracking and dissection technique (reproduced with permission from reference ). The retrograde guidewire reaches the distal CTO cap (panel 1A) and is advanced into the CTO subintimal space (panel 1B). A balloon is advanced over the retrograde guidewire into the subintimal space (panel 1C) where it is inflated (panel 1D), enabling advancement of the antegrade guidewire into the space created by the balloon (panel 1E), which communicates with the distal true lumen (panel 1F). Panel 2. Illustration of the CART, reverse CART and confluent balloon techniques (reproduced with permission from reference ).

Figure 7

Illustration of the “confluent balloon” technique. Chronic total occlusion of the proximal right coronary artery (arrow, panel A) with filling of the right posterior descending artery via a diffusely diseased saphenous vein graft with a distal anastomotic lesion (arrow, panel B). Using a Venture catheter (St Jude Medical) and a Pilot 200 wire (Abbott Vascular) formed into a knuckle (arrow, panel C), the CTO was crossed subintimally. A CrossBoss catheter (Bridgepoint Medical) was used for antegrade crossing (arrow, panel D), following by inflation of two 2.5 mm balloons (one advanced over the antegrade and one over the retrograde guidewire (arrow, panel E) (“confluent balloon” technique) the CTO was successfully crossed with an excellent result after stent implantation (panel F).

Figure 8

Acute side branch occlusion during a retrograde CTO intervention Chronic total occlusion of the mid right coronary artery that filled by a diffusely disease saphenous vein graft (panel A). A large acute marginal branch originated at the distal CTO cap (arrow, panel A and arrows, panel B). Successful retrograde recanalization was achieved using a retrograde true lumen puncture technique (panel C). After stent placement antegrade flow to the distal right coronary artery was restored but the acute marginal branches became occluded leading to inferolateral ST-segment elevation and post-procedural acute myocardial infarction.