Title
Acute vessel closure solved using the retrograde approach
Introduction
A 89 year-old man with prior coronary artery bypass grafting; patent SVG to D1, SVG to RCA, and failed LIMA to LAD graft underwent LAD PCI at an outside hospital after he failed medical therapy for refractory angina pectoris. The procedure was unsuccessful, complicated by wire dissection of LAD and cardiogenic shock managed with insertion of an Impella CP device. Following his recovery, he was referred to our center for reattempting PCI
Clinical Case
We obtained right femoral artery access (8F), and engaged the left main artery with an 8F EBU 3.5 guide catheter. Angiography revealed an eccentric, severely calcified mid LAD lesion with TIMI-2 flow. We failed to cross the lesion despite using a Caravel microcatheter and multiple guidewires (Sion Blue, Sion Black, Gaia Second, Pilot 200, Gladius). The patient developed chest pain and acute vessel closure. Right heart catheterization revealed elevated filling pressures, following which a 14F Impella CP sheath was placed in the left femoral artery. Left lower extremity run off revealed no flow after sheath placement (likely from dislodged calcific plaque occluding the lumen). Vascular surgery performed urgent surgical cutdown, repaired the CFA and reinserted the 14F sheath, with restoration of lower limb flow. An Impella CP device was inserted into the left ventricle and support was initiated. We then attempted retrograde crossing through an ipsilateral septal collateral, using a Caravel microcatheter, a Sion Black and a Suoh 03 wire. We were able to advance the guidewire and microcatheter distal to the distal cap. We performed retrograde wire escalation, successfully crossing distal cap into the proximal true lumen using a Pilot 200 guidewire. We inserted the retrograde guidewire into the antegrade guide catheter. However unable to advance the retrograde microcatheter through the lesion. We inserted a 7F EBU 3.5 through the Impella sheath using the single access technique. We were able to snare the retrograde wire using a 27-45mmEnsnare. Unfortunately, we were still unable to advance the retrograde microcatheter. We performed antegrade crossing attempts using the retrograde guidewire as a marker of the distal true lumen. Using Pilot 200, we were able to advance sub-intimally through the area of the occlusion. We inserted a Stingray LP balloon and did multiple reentry attempts without success. We then knuckled a Fielder XTA guidewire which successfully crossed into the distal true lumen as confirmed by advancing the antegrade microcatheter and transducing the pressure. The Fielder XTA was replaced by a Sion blue guidewire, followed by pre-dilatation and stenting of the mid LAD with 2 drug-eluting stents, using IVUS guidance with an excellent final result.
Discussion
Acute vessel closure can be a catastrophic complication in PCI, often requiring prompt insertion of hemodynamic support devices. Large bore sheaths can cause acute limb ischemia, thus lower limb angiography can be useful. Finally, CTO techniques can be very useful in non-CTO PCI, for example for treating acute vessel closure.