The antegrade dissection and re-entry technique as preparation of intravascular ultrasound guided re-wiring
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ORIGINAL ARTICLE
The antegrade dissection and re‑entry technique as preparation of intravascular ultrasound guided re‑wiring Wataru Takeuchi1 · Maoto Habara1 · Etsuo Tsuchikane1 · Takahiko Suzuki1 Received: 1 August 2018 / Accepted: 14 January 2019 © Japanese Association of Cardiovascular Intervention and Therapeutics 2019
Abstract Although the antegrade dissection and re-entry technique (ADR) with Stingray system is one of the procedures for percutaneous coronary intervention (PCI) of chronic total occlusion (CTO), it has some risk of side-branch occlusion. This article reports a CTO case in the left circumflex artery successfully treated with combination use of ADR subintimal tracking and intravascular ultrasound (IVUS)-guided re-wiring without side-branch occlusion. Antegrade approach with single-wire and parallel-wire technique was failed. Retrograde approach through ipsilateral collateral was also failed. Therefore, the ADR was attempted and Stingray wire crossed through at the distal site of posterolateral (PL) branch. To avoid PL branch occlusion, IVUS-guided re-wiring to the true lumen was attempted. Finally, the CTO lesion was recanalized without any complication and 1 year follow-up angiography had good result. ADR as preparation of IVUS-guided re-wiring might be one of the useful procedures for those complex CTO cases. Keywords Chronic total occlusion · Intravascular ultrasound · Complications · Hybrid revascularization
Introduction
Case reports
Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) has been developing with the novel techniques and devices [1–5]. The antegrade dissection and reentry technique (ADR) with Stingray system is one of the techniques for subintimal tracking procedure to simplify and potentially improve antegrade recanalization success [6]; however, that has some risk of side-branch occlusion and subsequent myocardial infarction [7]. On the other hand, intravascular ultrasound (IVUS)-guided re-wiring technique is also one of the intentional re-wiring techniques after wire migration into subintimal space. However, it has the potential risk of enlarging the subintimal space causing the failure of the wire cross [8]. In this paper, we report a CTO case successfully recanalized without side-branch occlusion with combination use of ADR subintimal tracking and IVUSguided intentional re-wiring.
A 62-year-old male with a history of diabetes, dyslipidemia, and hypertension, presented with chest pain on effort. Stress myocardial scintigraphy showed the posterolateral wall ischemia of left ventricle. Coronary angiogram revealed blunt-type CTO in mid-left circumflex artery (LCX) and ipsilateral collateral was found (Fig. 1). He was admitted our hospital and revascularization for the CTO lesion was attempted. At first, we performed angiogram of right coronary artery (RCA) to check the collaterals for left coronary artery (LCA). However, there was no interventional collateral for LCA from RCA. An 8-Fr. XB 3.5 guiding catheter (Brite tip, Cordis, OH) was engaged in
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