Korean Circ J.  2018 Apr;48(4):277-286. 10.4070/kcj.2017.0345.

Interventional Management of “Balloon-Uncrossable” Coronary Chronic Total Occlusion: Is There Any Way Out?

• Dash D

• KMID: 2407897
• DOI: http://doi.org/10.4070/kcj.2017.0345

Abstract

It has been estimated that coronary chronic total occlusion (CTO) is encountered in 15 to 20% patients referred for coronary angiography (CAG). The success of percutaneous coronary intervention (PCI) of CTO can be attributed to the vast array of hardware that has now become available and also to the vastly enhanced operator expertise. It is however realistic to state that despite the tremendous increase in the rate of success, there then comes a subset of CTO where PCI attempts fail. The reason for such failures given that other variables remain constant is the inability to cross the CTO lesion. This can be due to a failure to cross the lesion with a guide wire (despite guide wire escalation). The second cause of failure is the inability to cross the lesion with a balloon (balloon-uncrossable [BU] CTO). This can occur despite the successful placement of a guidewire in the distal true lumen. The BU lesions contribute 2% to 10% of CTO PCI failure cases. The author attempts to present a creative solution to assist crossing such lesions.

Keyword

Chronic total occlusion; Percutaneous coronary intervention; Balloon-uncrossable

MeSH Terms

Coronary Angiography
Humans
Percutaneous Coronary Intervention

Figure

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  Figure 1 Algorithm for crossing a BU CTO.BU = balloon-uncrossable; CTO = chronic total occlusion.

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  Figure 2 Schematic illustration of augmentation of guide catheter back up by guide extension catheter.

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  Figure 3 (A) Engagement of LMCA ostium with 6 F EBU 3.5 guide catheter to address long mid segment CTO of LAD artery. (B) Failure of 1.25×12 mm balloon to cross the lesion after insertion of Gaia 2 guidewire followed by navigation of 2.1 F Tornus catheter. (C) A 2×12 mm balloon in diagonal artery acts as an anchor. (D) Final result after deployment of 2 overlapping DES.CTO = chronic total occlusion; DES = drug-eluting stent; LAD = left anterior descending; LMCA = left main coronary artery.

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  Figure 4 Schematic illustration of side branch anchor balloon technique.CTO = chronic total occlusion.

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  Figure 5 (A) Engagement of RCA ostium with 6 F Hockey Stick 4.0 guide catheter to address long segment CTO of ostio-proximal segment with bridging collateral. (B) Navigation of 2.1 F Tornus (in BU lesion) after Gaia 3 guidewire penetrates the proximal cap to be positioned in the distal true lumen. (C) Final result after spot stenting in long calcified lesion.BU = balloon-uncrossable; CTO = chronic total occlusion; RCA = right coronary artery.

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  Figure 6 (A) Engagement of RCA ostium with 6 F AL 1guide catheter to address CTO of proximal segment with bridging collateral. (B) Facilitation of balloon crossing by Corsair microcatheter after Gaia 2 guidewire crosses the lesion. (C) Final result after deployment of 2 overlapping DES.CTO = chronic total occlusion; DES = drug-eluting stent; RCA = right coronary artery.

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  Figure 7 (A) Engagement of LMCA ostium with 6 F XB 3.0 guide catheter to fix long mid segment CTO of LAD. (B) Navigation of Gaia 2 guidewire across the occlusion into distal true lumen. (C) Rotational atherectomy with 1.25 mm burr to facilitate lesion crossing with balloon. (D) Final result after 2 overlapping DES.CTO = chronic total occlusion; DES = drug-eluting stent; LAD = left anterior descending; LMCA = left main coronary artery.

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