Intravascular lithotripsy (IVL)-facilitated balloon-assisted subintimal entry (BASE) to deal with an impenetrable proximal cap during CTO PCI
Presenter
Reza Masoomi, M.D., The University of Washington, Seattle, WA
Silvia Moscardelli, The University of Washington, Milan, WA, Italy, Reza Masoomi, M.D., The University of Washington, Seattle, WA and Lorenzo Azzalini, MD, PhD, MSc, FSCAI, The University of Washington, Shoreline, WA
Title
Intravascular lithotripsy (IVL)-facilitated balloon-assisted subintimal entry (BASE) to deal with an impenetrable proximal cap during CTO PCI
Introduction
70-year-old man s/p CABG in 1994 (SVG-LAD, SVG-OM, SVG-RCA), s/p PCI to RCA and LCx, ischemic cardiomyopathy with ICD, presenting with anterior STEMI. LVEF was 28% and LVEDP 25 mmHg. An IABP was implanted at the referring hospital, and the patient was transferred to our institution. Coronary angiography showed acute thrombotic subtotal occlusion of the SVG-LAD. The native LAD CTO had ambiguous proximal cap, was severely calcified, ~35 mm long, and the distal vessel was visualized through the failing graft.
Clinical Case
The decision was made to initially stabilize the SVG-LAD with IVUS-guided direct stenting, and to recanalize the LAD-CTO during the same procedure. This resulted in no reflow and severe hypotension, requiring Impella implantation. The patient became more stable and LAD CTO PCI was attempted. Both the proximal and distal caps were impenetrable with high-tipload wires, and side-BASE (balloon-assisted subintimal entry) was attempted into a septal branch at the proximal cap to no avail. The procedure was aborted. The patient recovered and was discharged 9 days later.
One month later he was brought back for reattempt. Bilateral 8F femoral access was secured, and 8F guide extensions were used bilaterally. IVUS was performed in the proximal LAD, showing 360 degrees of calcium. Intravascular lithotripsy (IVL) was performed with a 4.0 mm Shockwave C2+ balloon to fracture the calcium. BASE was performed with a 4.0 mm NC balloon followed by a Gladius wire, which was advanced antegradely in an extraplaque fashion. A retrograde system was advanced via the SVG-LAD, and reverse CART was successfully performed with a 3.0 mm NC balloon and a Gladius. Externalization was performed with an R350. Two stents were implanted from the distal LAD to the LM. Due to competitive flow, the SVG-LAD was embolized with a combination of a 5.0-7.0 mm Medtronic MicroVascular Plug and a 5.0 mm x 30 cm Penumbra Ruby Coil LP. Final angiographic and IVUS result on the native LAD was excellent.
Discussion
Impenetrable caps can be dealt with a variety of approaches. In our case, IVL was key in facilitating BASE and solving the case. IVUS has a fundamental role in: 1) sizing the balloon for BASE, 2) indicating IVL before BASE in case of concentric calcification.