Author + information
- Received December 5, 2016
- Accepted December 16, 2016
- Published online February 15, 2017.
- Nikhil V. Joshi, MD, PhDa,b,∗ (, )
- James C. Spratt, MDa,c,
- Simon Wilson, MDa,b,
- Simon J. Walsh, MDd and
- Colm G. Hanratty, MDd
- aFrom the Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
- bCentre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- cForth Valley Royal Hospital, Larbert, United Kingdom
- dDepartment of Cardiology, Belfast Health and Social Care Trust, Belfast, United Kingdom
- ↵∗Address for correspondence:
Dr. Nikhil V. Joshi, SU 305, Chancellors Building, 49, Little France Crescent, Edinburgh EH16 4SB, United Kingdom.
Percutaneous coronary intervention for chronic total occlusions (CTO) in patients with coronary artery bypass graft remains a challenge (1–3). The use of the graft as a retrograde conduit to recanalize native vessel occlusions is well-described in the presence of a degenerated, severely diseased graft (3), yet this technique is technically challenging if the distal CTO cap is close or at the graft anastomosis. We describe a novel technique using antegrade dissection re-entry to revascularize native vessel CTOs supplied by a diseased graft (Figure 1). The prerequisites for this technique are location of the occluded segment proximal to the graft insertion and a landing zone (area of vessel prior to a major bifurcation) in the native vessel distal to the graft insertion.
The relative ease and applicability of this technique offers the potential to improve the procedural success rates associated with CTO percutaneous coronary intervention in patients with post-coronary artery bypass graft. The technique involves first delivering a balloon to the “landing zone” (Figure 2) via a graft with the aim of using it as a target for Stingray (Boston Scientific, Marlborough, Massachusetts) re-entry. The next step is to access the subintimal space of the native chronically occluded segment with the aim of delivering first a wire and then the Stingray balloon to the subintimal space parallel to the (luminal) balloon. The balloon in the true lumen is then inflated to maximize the target for re-entry and the Stingray wire used to penetrate through the tissue plane aiming to “puncture” the balloon. The balloon is deflated, and the Stingray wire driven through the tissue planes and exchanged for a workhorse wire to complete the procedure. The facilitated antegrade dissection re-entry technique directly addresses some of the issues associated with higher failures rates in patients with previous coronary artery bypass graft: higher contrast use, radiation exposure, and procedural times.
Dr. Walsh is a consultant for Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 5, 2016.
- Accepted December 16, 2016.
- American College of Cardiology Foundation
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