Author + information
- Received July 6, 2016
- Revision received August 31, 2016
- Accepted September 8, 2016
- Published online November 28, 2016.
- aDivision of Cardiology, York Hospital, York, Pennsylvania
- bEmory University, Atlanta, Georgia
- cDivision of Cardiology, Phoenixville Hospital, Phoenixville, Pennsylvania
- ↵∗Reprint requests and correspondence:
Dr. William Nicholson, Division of Cardiology, York Hospital, York, Pennsylvania, 25 Monument Road, Suite 200, York, Pennsylvania 17403.
Percutaneous revascularization of ostial right coronary artery (RCA) chronic total occlusions (CTO) are challenging due to the lack of antegrade strategy options. A retrograde approach is mandated and when passage of the guidewire through the true lumen is unsuccessful, use of aggressive stiff tapered guidewires to puncture into the aorta at or near the RCA ostium is required for success. We describe a novel application of delivering electrical energy through a coronary guidewire to facilitate aortic entry (1) when stiff tapered guidewires alone failed to cross.
A 70-year-old man with an ostial RCA CTO presented with class IV angina despite maximal medical therapy. Retrograde access into the proximal RCA was gained via collateral connections from the left anterior descending artery. After baseline angiography (Figure 1) a retrograde guidewire was advanced subintimally to the ostium of the RCA (Figure 2). Attempts at direct puncture into the aorta with multiple stiff tapered guidewires failed. The distal 3 mm tip of a Confianza Pro 12 guidewire (Asahi Intecc, Nagoya, Japan) was removed and the wire was aimed at the RCA ostium. A pigtail catheter was placed in the aorta at the site of the ostial occlusion of the RCA as an anatomic landmark (Figure 3); left anterior oblique and right anterior oblique projections were obtained to ensure proper alignment (Figure 4). The proximal end of the guidewire was connected to a unipolar electrosurgery pencil using forceps (Figure 5) and the ground pad was placed on the patient. The guidewire was energized in cutting mode at 50 W for a 1-s burst, with immediate crossing into the lumen of the aorta (Figure 6). Guidewire snaring, externalization, and neo-ostial stenting of the RCA was then performed with standard CTO techniques (Figure 7).
Our case demonstrates the first delivery of electrical energy through a guidewire in coronary CTO percutaneous coronary intervention when standard strategies failed.
Dr. Nicholson has served on the speakers bureau for Abbott Vascular and Boston Scientific; has received consulting/proctoring fees from Abbott Vascular, Boston Scientific, and Asahi Intecc; has reported intellectual property from Vascular Solutions; and is on the advisory boards for Boston Scientific and Abbott Vascular. Dr. Harvey has served on the speakers bureau for AstraZeneca. Dr. Dhawan has reported that he has no relationships relevant to the contents of this paper to disclose.
- Received July 6, 2016.
- Revision received August 31, 2016.
- Accepted September 8, 2016.
- American College of Cardiology Foundation