Subintimal plaque modification (SPM) (also termed as an “investment procedure”) by subintimal tracking and re-entry (STAR) with subsequent balloon dilatation is a bailout strategy in failed chronic total occlusion (CTO) percutaneous coronary intervention (PCI) [1]. Little is known about the treatment of long-tract dissections resulting from unsuccessful SPM at follow-up.
A 74-year-old female with a history of diabetes mellitus presented with Canadian Cardiovascular Society class III angina. Transthoracic echocardiography showed preserved left ventricular ejection fraction. Coronary angiography demonstrated CTO of the proximal right coronary artery (RCA) with a blunt proximal cap and high tortuosity (J-CTO score 2) (Figure 1A, Supplementary material, Video S1). After failed CTO recanalization using antegrade wiring, controlled antegrade dissection and re-entry, and futile retrograde collateral crossing, the STAR technique was attempted in the distal RCA.
Since the knuckle wire failed to re-enter into the true RCA lumen and went into the extraplaque position along the posterolateral artery, SPM was performed using a semi-compliant 3.0 mm balloon in the mid-to-distal RCA (Figure 1B, C, Supplementary material, Videos S2, S3). Angiography after 3 months showed a long-tract double-barrel dissection with obstructive residual stenosis in the distal RCA (Figure 1D, Supplementary material, Video S4). Based on the patient’s persisting symptoms, the decision to reconstruct the RCA true lumen was undertaken. To this end, intravascular ultrasound (IVUS) was used for localization of the true lumen entry, and puncture using the Gaia Third guidewire (Asahi Intecc, Nagoya, Japan) was performed (Figure 1E, Supplementary material, Videos S5, S6). After IVUS confirmation of Gaia Third’s intraluminal position, a double-lumen microcatheter was advanced through the entry site, and the posterior descending artery was successfully wired using the Sion Blue guidewire (Asahi Intecc, Nagoya, Japan) (Figure 1F, G, Supplementary material, Video S7). Following true-to-true lumen dilatation, repeated angiography and IVUS performed after 2 months showed complete resolution of RCA false lumen with Thrombolysis in Myocardial Infarction (TIMI) 3 flow (Figure 1H, I, Supplementary material, Video S8). The patient remained asymptomatic at 6-month follow-up.
The presence of false lumen dissections compromising distal coronary flow is not a benign complication of SPM at follow-up. Herein, we introduce the IVUS-guided antegrade wiring as a novel CTO PCI strategy for staged reconstruction of CTO true lumen after failed SPM in lesions with limited retrograde access.
Supplementary material
Supplementary material is available at https://journals.viamedica.pl/kardiologia_polska
Article information
Conflict of interest: None declared.
Funding: This work was supported by a statutory grant from the National Institute of Cardiology in Warsaw (ID: 2.59/III/20).
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