Ad-hoc CTO with intramural haemathoma.

Author: Javier Leon Jimenez – UNIVERSITARY HOSPITAL JEREZ.

INTRODUCTION

Introduction about treatment strategy: DES vs DCB

Chronic total occlusions (CTO) pose a challenge for the interventional cardiologist. These are the most complex coronary procedures, which require experience and specific training to achieve adequate success rates.

Although there are some scenarios in the world of CTOs in which the drug-eluting balloon could be useful, given the complexity and characteristics of the lesions, the drug-eluting stent remains the preferred option for the interventional cardiologists.

CASE REPORT: INTERVENTION

We present the case of a 73-year-old man with excellent quality of life and a personal history of arterial hypertension, right carotid stroke without sequelae, and chronic pancreatitis, who was admitted for a moderate-risk non-ST-segment elevation myocardial infarction (Grace Score 126 points). Echocardiography showed a preserved ejection fraction without segmental abnormalities in contractility.

Coronary angiography was requested, which was carried out through a 6F right radial access, in which a coronary tree of normal distribution and right dominance was observed, with a coronary trunk, a left anterior descending coronary, and a left circumflex coronary without lesions (Fig 1). At the level of the right coronary artery, a severe proximal plaque suggestive of a recanalized thrombus was evidenced, as well as a chronic occlusion of the middle segment, with a distal bed of good caliber and development, visible from homo and heterocoronary circulation. (Video 1 RC)

Strategy possibilities discussion: What are you going to use, DES or DCB; why?

Initially, a delayed approach to the occlusion was considered, although the patient requested “ad hoc” revascularization. Given the apparent simplicity of the procedure (J-CTO Score: 0), we opted for an antegrade approach through a 6F radial access, without contralateral control.

Although we have some experience in the management of chronic total occlusion with drug-eluting balloons, we usually reserve this strategy for patients with a very high risk of bleeding, in whom the result of lesion preparation is optimal. In our patient, as the case progresses, this option was ruled out, opting for the implantation of drug-eluting stents.

Procedure.

Through the AWE technique, progress was achieved through the occlusion using a PILOT 150 guide with the support of a 1.5*10mm OTW balloon (after previous attempts with SION, Fielder XT-A and Gaia First wires). (Video 2 RC)

The angiography after crossing the CTO with the guidewire was suggestive of a wide coronary dissection (Video 3 RC), which is why IVUS was attempted, not being possible to progress the catheter through the mid segment, which is why injections were performed through the OTW-balloon and a micro catheter were done at the distal level of the artery, confirming the presence of the guidewire in true lumen.(Video 4 RC) Subsequently, predilations were performed with a 1.2*8mm and 2*10mm semi-compliant balloons at 18atm, finally managing to progress the IVUS, in which a large coronary dissection with intraparietal hematoma is evident that compromises the entire proximal, middle and distal segment of the right coronary. (Image IVUS 1-2-3 and video 1).

For this reason, we decided to implant a drug-eluting stents Angiolite Rx 2.5*39mm in the distal segment, a 3*39mm in the proximal segment, and finally a 2.5*34mm in the middle segment, overlapped with the other 2 previous, in order to avoid the hematoma expansion (Fig 2-3-4). Finally, an aggressive post-dilatation with a non-compliant balloon 3*15mm at 30atm was performed on the proximal and middle segments, achieving an excellent angiographic result. (Video 5 RC).

Final comments

In complex scenarios such as chronic total occlusions, the proper choice of material is essential to achieve the final success of the procedure. The combined use of intracoronary diagnostic techniques and high-performance stents, like Angiolite RX with low rates of restenosis, not only facilitate the procedure and reduce short-term complications, but also avoid late complications and reinterventions.

EuroIntervention 2019;15:e1081-e1089
Circulation 2019 Jul 30; 140(5):420-433