Side-Power Knuckle and Antegrade Dissection Reentry Techniques – Novel Techniques in CTO PCI
Presenter
Michael S Megaly, M.D., FSCAI, Henry Ford Hospital, Bossier City, LA
Michael S Megaly, M.D., FSCAI, Henry Ford Hospital, Bossier City, LA
Title
Side Power Knuckle And Antegrade Antegrade Dissection Reentry Techniques, novel techniques in CTO PCI
Introduction
Proximal cap ambiguity and retrograde options in patients with prior CABG can be challenging
Clinical Case
A 67-year-old man presented with unstable angina for a week. He has a history of previous bypass graft surgery with patent grafts to the left anterior descending artery (LAD) and diagonal branch and occluded SVG to the posterior descending artery (PDA), and a degenerative aneurysmal SVG to an obtuse marginal branch (OM). He was referred for chronic total occlusion percutaneous coronary intervention (CTO PCI) and occlusion of the aneurysmal SVG.The OM CTO was complex, long, and with ambiguous proximal and distal caps. We identified the location of the proximal cap using intravascular ultrasound (IVUS) and marked it on cineography. We then performed the power side knuckle technique (SPK) as follows: we inflated a 1:1 sized balloon entrapping a microcatheter (MC) in the left circumflex artery (LCX) with the MC tip at the marked location of the proximal cap; advanced a non-tapered stiff polymer-jacketed wire (Pilot 200, Abbott Vascular, USA) that knuckled into the OM and advanced the knuckle to the distal cap. We then performed the antegrade antegrade dissection re-entry technique (AADR), which is a novel technique similar to the reverse controlled antegrade and retrograde dissection reentry (reverse CART) but with utilizing the antegrade limb of a bypass conduit. We inflated a 1:1 sized balloon in the antegrade limb of the SVG at the distal cap and directed a highly penetrative wire (Confianza pro 12, ASAHI INTCC) to connect the 2 spaces into the distal true lumen. We completed stenting of the OM branch with final kissing balloons into the LCX. We then occluded the SVG using an Amplatzer vascular plug 4 device (Abbott, USA) delivered through a an 0.35 MC with final occlusion of the SVG and final excellent angiographic result.
Discussion
Our novel techniques would help overcome proximal cap ambiguity and retrograde approach challenges in patients with prior CABG