'Seesaw Balloon-Wire Cutting' and Chronic Total Occlusions
'Seesaw Balloon-Wire Cutting' and Chronic Total Occlusions
Between July 2012 and May 2013, a total of 105 patients with CTO lesions in native coronary arteries underwent PCI in our catheterization laboratory. The indication of PCI was the presence of symptomatic angina or documented silent myocardial ischemia. PCI was performed according to standard clinical protocol. Routine dosages of aspirin and clopidogrel were given to all patients before and after the procedure. Unfractionated heparin was administered intravenously to achieve a target activated clotting time of 250 seconds. Transradial approach was chosen in most patients. Guiding catheters like EBU, Heartrail BL, or Amplatz were often used to provide better support. Intraluminal location of the distal tip of the guidewire was confirmed in multiple views by contrast filling the distal bed via contralateral or ipsilateral injection. Drug-eluting stents were implanted after balloon predilation. During the PCI procedure, twenty-one out of 105 patients had unsuccessful attempts of crossing the occluded lesion with the available lowest-profile balloon following successful guidewire passage. Initially, we tried the multiwire crushing technique in most patients and the anchor balloon technique in 5 patients, but they all failed. Therefore, we applied the "seesaw balloon-wire cutting" technique in these patients. The main process of the novel technique consisted of the following steps: a guidewire (guidewire A) was first inserted into the distal true lumen of CTOs, and then another stiffer hydrophilic guidewire (guidewire B) was slowly manipulated to cross the occluded segment along with guidewire A; two short and low-profile balloons (balloon A and balloon B, chosen from 1.2 × 6 mm MiniTREK, Abbott; 1.25 × 6 mm Sprinter Legend, Medtronic; or 1.25 × 10 mm Tazuna, Terumo) were advanced over the two guidewires, respectively; balloon A was first advanced over guidewire A as distally as possible, and then the balloon was inflated with high pressure (≥18 atm) to press guidewire B, producing a cutting power to crush the proximal fibrous cap of the CTOs. Subsequently, balloon A was withdrawn slightly, and balloon B was advanced as distally as possible and then was inflated to press guidewire A, producing a similar cutting effect to crush the proximal fibrous cap on the other side; the two balloons were progressed alternatively until one of them was able to cross through the occluded segment (Figure 1).
(Enlarge Image)
Figure 1.
Illustration of the main process of the "seesaw balloon-wire cutting" technique. Following the positioning of two guidewires (guidewire A and guidewire B) into the distal true lumen of the chronic total occlusion (CTO), two short and low-profile balloons (balloon A and balloon B) are advanced over the two guidewires, respectively. The two balloons are progressed alternatively to cut the proximal fibrous cap of the occlusion in different positions until one of them is able to cross through the occluded segment. WA = guidewire A; WB = guidewire B; BA = balloon A; BB = balloon B.
A chronic total occlusion was defined as a lesion exhibiting thrombolysis in myocardial infarction (TIMI) flow grade 0 or grade 1 with duration of ≥3 months. The duration of coronary occlusion was estimated from clinical events including myocardial infarction, sudden onset or worsening of the symptoms that were consistent with the occlusion location, or proved by previous coronary angiography. Technique success was defined as the balloon crossing through CTOs successfully after the seesaw balloon-wire cutting procedure. PCI success was defined as the restoration of TIMI flow grade 3 with a residual stenosis of <20% in target CTOs after stent implantation.
Continuous parameters were presented as mean ± standard deviation. Discrete parameters were reported as percentages. All analyses were performed using SPSS 19.0.
Methods
Patients and PCI Procedure
Between July 2012 and May 2013, a total of 105 patients with CTO lesions in native coronary arteries underwent PCI in our catheterization laboratory. The indication of PCI was the presence of symptomatic angina or documented silent myocardial ischemia. PCI was performed according to standard clinical protocol. Routine dosages of aspirin and clopidogrel were given to all patients before and after the procedure. Unfractionated heparin was administered intravenously to achieve a target activated clotting time of 250 seconds. Transradial approach was chosen in most patients. Guiding catheters like EBU, Heartrail BL, or Amplatz were often used to provide better support. Intraluminal location of the distal tip of the guidewire was confirmed in multiple views by contrast filling the distal bed via contralateral or ipsilateral injection. Drug-eluting stents were implanted after balloon predilation. During the PCI procedure, twenty-one out of 105 patients had unsuccessful attempts of crossing the occluded lesion with the available lowest-profile balloon following successful guidewire passage. Initially, we tried the multiwire crushing technique in most patients and the anchor balloon technique in 5 patients, but they all failed. Therefore, we applied the "seesaw balloon-wire cutting" technique in these patients. The main process of the novel technique consisted of the following steps: a guidewire (guidewire A) was first inserted into the distal true lumen of CTOs, and then another stiffer hydrophilic guidewire (guidewire B) was slowly manipulated to cross the occluded segment along with guidewire A; two short and low-profile balloons (balloon A and balloon B, chosen from 1.2 × 6 mm MiniTREK, Abbott; 1.25 × 6 mm Sprinter Legend, Medtronic; or 1.25 × 10 mm Tazuna, Terumo) were advanced over the two guidewires, respectively; balloon A was first advanced over guidewire A as distally as possible, and then the balloon was inflated with high pressure (≥18 atm) to press guidewire B, producing a cutting power to crush the proximal fibrous cap of the CTOs. Subsequently, balloon A was withdrawn slightly, and balloon B was advanced as distally as possible and then was inflated to press guidewire A, producing a similar cutting effect to crush the proximal fibrous cap on the other side; the two balloons were progressed alternatively until one of them was able to cross through the occluded segment (Figure 1).
(Enlarge Image)
Figure 1.
Illustration of the main process of the "seesaw balloon-wire cutting" technique. Following the positioning of two guidewires (guidewire A and guidewire B) into the distal true lumen of the chronic total occlusion (CTO), two short and low-profile balloons (balloon A and balloon B) are advanced over the two guidewires, respectively. The two balloons are progressed alternatively to cut the proximal fibrous cap of the occlusion in different positions until one of them is able to cross through the occluded segment. WA = guidewire A; WB = guidewire B; BA = balloon A; BB = balloon B.
Definitions
A chronic total occlusion was defined as a lesion exhibiting thrombolysis in myocardial infarction (TIMI) flow grade 0 or grade 1 with duration of ≥3 months. The duration of coronary occlusion was estimated from clinical events including myocardial infarction, sudden onset or worsening of the symptoms that were consistent with the occlusion location, or proved by previous coronary angiography. Technique success was defined as the balloon crossing through CTOs successfully after the seesaw balloon-wire cutting procedure. PCI success was defined as the restoration of TIMI flow grade 3 with a residual stenosis of <20% in target CTOs after stent implantation.
Statistical Analyses
Continuous parameters were presented as mean ± standard deviation. Discrete parameters were reported as percentages. All analyses were performed using SPSS 19.0.
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