Bi-Radial Chronic Total Occlusion PCI Using Ping-Pong Guide Technique
Shahrukh N Bakar, M.D., London Health Sciences Centre, London, ON, Canada
Shahrukh N Bakar, M.D., London Health Sciences Centre, London, ON, Canada
Authors: Shahrukh N. Bakar, MD; Rodrigo Bagur, MD, PhD Title: Bi-Radial Chronic Total Occlusion PCI using Ping-Pong Guide Technique Introduction: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is indicated for ischemic symptoms refractory to optimal medical therapy. Patients with CTOs often have multiple comorbidities that may include severe left ventricular (LV) systolic dysfunction and complex coronary anatomy. Some operators forego well-established benefits of radial access in terms of access site-related complications due to perceptions of poor guide catheter support. We present a case of high-risk CTO PCI of a dominant left circumflex with severe LV dysfunction using bi-radial access. Clinical Case: A 74-year old male presented with CCS III angina and heart failure reduced LV ejection fraction (LVEF 20%) despite optimal medical therapy. Past medical history included non-ST elevation myocardial infarction at which time cardiac catheterization demonstrated CTO of a large, dominant left circumflex immediately distal to 1st obtuse marginal (OM1); this was managed medically. Repeat angiography showed unchanged anatomy. Thallium-201 scintigraphy showed significant inferolateral myocardial viability. Due to refractory ischemic symptoms, severe LV systolic dysfunction and significant viability, CTO PCI was offered by the Heart Team. Bi-radial access was used with a 7-French GlideSheath Slender (Terumo Corp, Somerset, NJ, USA) in the right radial artery for antegrade 7-French XB 3.5 guide catheter and a 6-French GlideSheath Slender in the left radial artery for retrograde access with 6-French XB 3.5 guide catheter. Angiography revealed several large ipsilateral septal collaterals from the left anterior descending (LAD) to OM branches. Antegrade wire escalation was first attempted using a Fielder XT, Pilot 50, Pilot 200, and a Hornet 14 wire with Turnpike Spiral microcatheter but was unable to cross the proximal cap. We then switched to a retrograde approach and used a Fielder XT for LAD septal surfing connecting to the distal circumflex and crossed the distal cap. We were unable to penetrate the proximal cap via the retrograde approach despite multiple wires (Pilot 200, Gaia Third, Hornet 14, Confianza Pro 12). We considered antegrade dissection re-entry; however, this would have compromised flow in the large OM1. Fortunately, after a few extra maneuvers, a Pilot 200 successfully crossed the proximal cap in a true-to-true fashion and was confirmed in orthogonal projections prior to exchanging for a workhorse Sion Blue wire over microcatheter. The retrograde wire and microcatheter were then removed. Serial balloon dilatations were used, and four drug-eluting stents were delivered conventionally from the mid-distal to proximal circumflex artery. The OM1 origin was compromised; therefore, provisional T-stenting with kissing balloon inflation was performed at the bifurcation with excellent angiographic result. Residual distal left circumflex disease was left for medical management. Discussion: Bi-radial access is a well-validated and safe option for high-risk CTO PCI that avoids femoral access and its associated complications in a patient with multiple comorbidities. The use of ping-pong guide technique allowed for simultaneous antegrade and retrograde approaches in the left coronary system in the setting of dominant left circumflex with ipsilateral collaterals. Notably, percutaneous mechanical circulatory support was not used.