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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 105-109

Recanalizing a right coronary artery chronic total occlusion with J chronic total occlusion score 3: An interesting combination of reversal of wire upgradation and miniature balloon


Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission31-Jan-2022
Date of Decision28-Mar-2022
Date of Acceptance13-Apr-2022
Date of Web Publication12-Aug-2022

Correspondence Address:
Dr. Debasish Das
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_8_22

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  Abstract 


We represent a case of interesting right coronary artery chronic total occlusion (CTO) revascularization where traditional wire upgradation failed to cross the CTO. Downgrading it to a Miracle 3 wire, the lesion was successfully crossed. It was further dilated with the smallest balloon (NIC Nano 0.85 mm × 6 mm), followed by serial dilation with bigger size balloons. The present manuscript conveys a message that the rule of thumb of wire upgradation during CTO revascularization does not yield in success always, it is the downgradation of the wire which can also achieve success. CTO revascularization although it has some fixed principles, sometimes, a permutation and combination even giving a fair try with wire downgradation can achieve success.

Keywords: Chronic total occlusion, right coronary artery, wire downgradation


How to cite this article:
Das D, Banerjee A, Kumar A, Singh J, Das T, Singh S, Gupta JD, Pramanik S, Dixit M. Recanalizing a right coronary artery chronic total occlusion with J chronic total occlusion score 3: An interesting combination of reversal of wire upgradation and miniature balloon. Heart India 2022;10:105-9

How to cite this URL:
Das D, Banerjee A, Kumar A, Singh J, Das T, Singh S, Gupta JD, Pramanik S, Dixit M. Recanalizing a right coronary artery chronic total occlusion with J chronic total occlusion score 3: An interesting combination of reversal of wire upgradation and miniature balloon. Heart India [serial online] 2022 [cited 2022 Sep 27];10:105-9. Available from: https://www.heartindia.net/text.asp?2022/10/2/105/353737




  Introduction Top


Revascularization of a chronic total occlusion (CTO) carries some inherent principles of wire upgradation along with the use of some novel devices to facilitate antegrade CTO recanalization. Institutional and individual practice varies but many things remain in common which each individual adheres during CTO revascularization. During CTO revascularization in our laboratory, we opt for Fielder FC or Sion Black as the workhorse wire. Wire upgradation is done in the following order: Fielder FC or Sion Black followed by Fielder XT or Fielder XT A followed by Gaia 2 or Gaia 3. Use of conquest pro 12 wire in our laboratory is restricted as success in most of the CTO revascularization is achieved with those wires. Antegrade crossing is most often accomplished with balloon support; use of microcatheter is limited as most often with balloon support the CTO wire tunnels the CTO segment.


  Case report Top


A 60-year-old male presented with effort angina Canadian Cardiovascular Society Class II for the last 6 months. He was diabetic, hypertensive, and dyslipidemic with low-density lipoprotein of 200 mg/dl. He was a nonsmoker, and there was no family history of coronary artery disease. He was not able to climb one flight of stairs, was not able to carry a grocery bag for 200 meters and was on optimal medical therapy for the last 6 months. His treadmill test was strongly positive with significant ST depression of more than 2 mm in five leads. In view of drug refractory angina, he was subjected to right transradial coronary angiogram, which revealed long segment total occlusion of the right coronary artery (RCA) with J CTO score of 3.[1] The crux of CTO intervention was that he had a blunt CTO stump [Figure 1], and a right ventricular marginal branch was originating from the point of beginning of the CTO [Figure 1]. There was a long segment CTO of the RCA in mid-segment, and the distal vessel was not at all visible. We initially tried to cross the CTO segment with Fielder FC wire which is the workhorse wire of choice in our laboratory with a 1.5 mm × 8 mm balloon support which was repeated rushing into the marginal branch. Then, we upgraded the CTO wire to Fielder XT A (A for antegrade) which was also unable to penetrate the lesion with continuous drilling with proximal balloon support. As a last resort, we opted for Gaia 3 wire which was also not able to cross the lesion with a proximal balloon support and also with the microcatheter support. We thought of IVUS-guided penetration of the proximal CTO cap, but the patient was unaffordable for the same. In a random choice, we opted for the Miracle 3 wire which was there in the laboratory since long not used in the assumption it may provide a miracle. Miracle 3 wire was able to cross the CTO segment easily [Figure 2] with proximal balloon support. Miracle 3 wire assumed the classical C shape of the RCA indirectly indicating that the wire is in the lumen. We could not pass a 1.5 mm × 8 mm balloon across the CTO segment. We used the smallest balloon available in the laboratory (NIC Nano) balloon of 0.85 mm × 6 mm in size which crossed the lesion [Figure 3]. We dilated the lesion initially with this NIC Nano balloon (0.85 mm × 6 mm), followed by 1.5 mm × 8 mm and 2 mm × 10 mm balloon [Figure 4] which yielded the calcific plaque to some extent, followed by 2.5 mm × 10 mm noncompliant balloon. Traditionally, it is believed that proper wire upgradation results in CTO revascularization,[2] but in our case, downgradation of the wire with use of the most miniature balloon (NIC Nano) resulted in successful CTO revascularization. We deployed a 3 mm × 36 mm drug-eluting stent across the lesion [Figure 5] at 14 atmospheric (ATM) pressure which resulted in TIMI II flow [Figure 6], and the patient was hemodynamically stable postprocedure. Our take-home message from the manuscript is success in difficult CTO revascularization can also sometimes be achieved with wire downgradation and the use of miniature balloon. Success in CTO revascularization is not a fixed algorithm, a random choice can sometimes suffice also.
Figure 1: RCA CTO with J CTO Score 3. RCA: Right coronary artery, CTO: Chronic total occlusion

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Figure 2: Antegrade crossing with Miracle 3 wire

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Figure 3: Use of NIC Nano (0.85 mm × 6mm) balloon

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Figure 4: Use of routine 2 mm × 10 mm balloon

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Figure 5: Use of 3 mm × 36 mm DES. DES: Drug-eluting stent

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Figure 6: Final result with TIMI III flow

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  Discussion Top


Upgradation of CTO wire bears some inherent principles where wires with progressively increased tip load are exercised successively till the antegrade crossing is achieved. Each CTO has a hard proximal CTO cap and relatively softer distal cap that is why in difficult CTO intervention, retrograde attempt to cross the CTO often works when antegrade attempt fails to do the same. Blunt CTO cap, the origin of a side branch from the proximal part of the CTO, relatively long segment of CTO (>20 mm), complete nonvisibility of the distal vessel during antegrade injection, and also through retrograde collaterals during contralateral injection are few poor prognosticating factors in achieving success in CTO revascularization.[3] The crux of our case was the CTO had a blunt proximal cap, a large acute marginal branch was originating at the point of origin of CTO and there was relatively long length of CTO (>50 mm) with few intracoronary bridging collaterals which were negative predictive factors toward successful CTO revascularization. The CTO segment could not be crossed with the workhorse Fielder FC wire with balloon support, and the wire was repeated rushing into the marginal branch. Fielder XT A (A for Antegrade) wire, Gaia 3 wire with proximal balloon support and with the microcatheter could not penetrate the lesion. Randomly Miracle 3 wire was opted in the assumption it may provide a miracle and it passed. Downgradation to Miracle 3 wire worked, and the lesion was dilated with the smallest balloon (NIC Nano) balloon of 0.85 mm × 6 mm size followed by 1.5 mm × 8 mm and 2 mm × 10 mm balloon which yielded the calcific plaque to some extent followed by 2.5 mm × 10 mm noncompliant balloon.

Wire upgradation which is practiced in our laboratory is as follows [Figure 7]:
Figure 7: Steps of CTO wire upgradation. CTO: Chronic total occlusion

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Traditionally, it is believed that proper wire upgradation results in CTO revascularization, but in our case, downgradation of the wire to a Miracle wire with 3 g tip load and with the use of the most miniature NIC Nano (0.85 mm × 6 mm) balloon the CTO was recanalized. We deployed a 3 mm × 36 mm drug-eluting stent across the lesion at 14 ATM pressure which resulted in TIMI II flow and the patient was hemodynamically stable postprocedure. Our take-home message from the manuscript is success in difficult CTO revascularization can also sometimes be achieved with wire downgradation and the use of miniature balloon. CTO revascularization is not a fixed algorithm, a random choice can sometimes suffice also. Ashai Miracle wire comes with tip load of 3, 6, and 12 g. Although Miracle is believed a stalwart in CTO revascularization, one disadvantage is there remains a high likelihood of wire passing subintimal. Miracle wire has a greater role in long CTO without tortuosities with a clear course of the occluded vessel segment, and it should be avoided in the bends in the occluded segment and where the course of artery is not clear which may lead to a long segment of dissections. Antegrade or retrograde penetration of the CTO wire should always be confirmed in two orthogonal angiographic views. Retrograde injection opacifying through the collaterals better confirms whether the wire has entered into the distal true lumen or not. Retrograde injection is always helpful than multiple antegrade injections in revealing the exact position of the wire either intraluminal or subintimal.

CTO intervention is not usually abandoned before using the Gaia family of wires. Gaia 1 has a tip load of 1.7 g, whereas Gaia 2 has a tip load of 3.5 g, and Gaia 3 has a tip load of 4.5 g [Figure 8].
Figure 8: Tip Load of Gaia wire

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CTO intervention is started with a Fielder FC wire with a tip load of 0.8 g, which if fails is upgraded to Fielder XT-A with tip load of 1 g [Figure 9]. Few interventionists start the CTO intervention with Sion Black wire with same tip load of 0.8 g, but it is more slippery and offers slightly more crossability in few cases. Most often, antegrade crossing is sufficed with balloon support, and rarely microcatheter also helps in the same.[4] One disadvantage of microcatheter is the use of doc extension for wire exchange to the workhorse wire once the CTO is crossed. We could not cross the lesion with Gaia 3rd wire with a tip load of 4.5 g but with a Miracle wire with 3 g tip load we could cross the lesion. That is why few interventionists dictate: Miracle is a stalwart and sometimes makes a miracle happen. During CTO intervention, the wire should always be checked in two orthogonal or opposite views and it is prudent to know when the wire is subintimal. As a rule, subintimal wire tip does not move freely and offers unusual resistance during advancement.[5] Most of the CTO are initially crossed with 1.5-mm or 1-mm balloon.[6] However, in our case, it could not be crossed with 1.5-mm balloon for which the smallest available NIC Nano balloon (0.85 mm × 6 mm) was used which crossed the lesion and was able to produce small recanalization after which subsequent balloons of 2.0 mm and 2.5 mm crossed and yielded the lesion. Noncomplaint (NC) balloon, scoring balloon, and cutting balloon[7],[8] are also helpful in yielding calcific lesions. Very slow dilatation with a NC balloon is the dictum as rapid dilatation does not catch the lesion and melon seeding occurs. In our cases, the last use of 2.5-mm NC balloon yielded the lesion nicely after which conventional drug eluting stent was deployed with subsequent TIMI III flow. Our case is an interesting and rare illustration of CTO revascularization by reversal of wire upgradation when using a Miracle 3 wire which really did a miracle in achieving antegrade crossing of the CTO followed by use of a smallest balloon which facilitated the intervention. Reversal of wire upgradation can also achieve CTO revascularization as it has no hard and first rule in accomplishing success.
Figure 9: Tip Load of Fielder Wires

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  Conclusion Top


Our case is an interesting and rare illustration of successful CTO revascularization by reversal of wire upgradation and use of the smallest NIC Nano (0.85 mm × 6 mm) balloon. Interventionists should not backstep in wire downgradation along with random choice before giving up a CTO revascularization. Our case has a take-home message: CTO revascularization does not always adhere to fixed rules of wire upgradation; even downgradation and random choice can also make your morning successful.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical approval

Institutional Ethical Committee (IEC) permission has been obtained.

Authors' contributions

Debasish Das: Final Manuscript Editing Anindya Banerjee, Abhinav Kumar, Jogendra Singh, Tutan Das, Shashikant Singh, Jaideep Das Gupta: Manuscript Preparation Subhas Pramanik, Manaranjan Dixit: Image Editing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Christopoulos G, Wyman RM, Alaswad K, Karmpaliotis D, Lombardi W, Grantham JA, et al. Clinical utility of the Japan-chronic total occlusion score in coronary chronic total occlusion interventions: Results from a multicenter registry. Circ Cardiovasc Interv 2015;8:e002171.  Back to cited text no. 1
    
2.
Dash D. Guidewire crossing techniques in coronary chronic total occlusion intervention: A to Z. Indian Heart J 2016;68:410-20.  Back to cited text no. 2
    
3.
Mishra S. Unraveling the mystique of CTO Interventions: Tips and techniques of using hardware to achieve success. Indian Heart J 2017;69:266-76.  Back to cited text no. 3
    
4.
Mishra S. Language of CTO interventions – Focus on hardware. Indian Heart J 2016;68:450-63.  Back to cited text no. 4
    
5.
Brilakis ES, Grantham JA, Rinfret S, Wyman RM, Burke MN, Karmpaliotis D, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv 2012;5:367-79.  Back to cited text no. 5
    
6.
Nguyen TN, Sumitji S, Han Y, Saito S. Chronic total occlusion. In: Practical Handbook of Advanced Interventional Cardiology: Tips and Tricks. 4th ed. Wiley Black Well Publishers, Hoboken, New Jersey, USA: John Wiley and Sons; 2012.  Back to cited text no. 6
    
7.
Dash D. Interventional management of “balloon-uncrossable” coronary chronic total occlusion: Is there any way out? Korean Circ J 2018;48:277-86.  Back to cited text no. 7
    
8.
Nakabayashi K, Okada H, Oka T. The use of a cutting balloon in contemporary reverse controlled antegrade and retrograde subintimal tracking (reverse CART) technique. Cardiovasc Interv Ther 2017;32:263-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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