Korean Circ J.  2019 Jul;49(7):559-567. 10.4070/kcj.2019.0160.

A Technical Focus on Antegrade Dissection and Re-entry for Coronary Chronic Total Occlusions: a Practice Update for 2019

• Walsh SJ
• Cosgrove C
• Spratt JC
• Hanratty C

• KMID: 2450387
• DOI: http://doi.org/10.4070/kcj.2019.0160

Abstract

Coronary chronic total occlusions (CTOs) are a commonly encountered lesion. These present in a diverse patient population with variable anatomy. Technical success rates of ~90% are achievable for CTO lesions in centers with appropriate expertise. Many lesions can be crossed with wire-based techniques. However, the most anatomically complex and technically challenging lesions will often require more advanced approaches such as retrograde access and/or the application of blunt dissection techniques in the vessel to safely navigate long and/or ambiguous CTO segments. Retrograde dissection and re-entry (RDR) and antegrade dissection and re-entry (ADR) strategies are often needed to treat such lesions. In many circumstances, ADR offers a safe and efficient means to successfully cross a CTO lesion. Therefore, operators must remain cognizant of the risks and benefits of differing technical approaches during CTO percutaneous coronary intervention, particularly when both ADR and RDR are feasible. This article provides an overview of the ADR technique in addition to updated approaches in contemporary clinical practice.

Keyword

Percutaneous coronary intervention; Chronic total occlusion; Antegrade dissection and re-entry

MeSH Terms

Humans
Percutaneous Coronary Intervention
Risk Assessment

Figure

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  Figure 1 The CrossBoss and Stingray catheters.

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  Figure 2 Example of ADR as a bailout for sub-intimal wire passage in contemporary practice. (A) There is a 25–30mm CTO of the mid RCA. (B) A Pilot 200 advances into the CTO and beyond the distal cap but is in a subintimal position. (C) Blunt dissection is not required, rather the micro-catheter is advanced to the landing zone to facilitate delivery of the Stingray. (D) The Stingray is exchanged into the vessel, inflated and orientated with the target vessel on the left of the balloon. (E) Final result after successful re-entry and vessel reconstruction. ADR = antegrade dissection and re-entry; CTO = coronary chronic total occlusion; RCA = right coronary artery; RV = right ventricular; SIS = sub-intimal space.

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  Figure 3 Ideal anatomy for a primary ADR procedure using the CrossBoss and Stingray system ADR = antegrade dissection and re-entry; CTO = coronary chronic total occlusion; PDA = posterior descending artery; PLV = posterolateral vessel.

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  Figure 4 Development of intramural hematoma and compression of the distal landing zone if the sub-intimal space is exposed to systemic blood flow.

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  Figure 5 Treatment of the lesion depicted in Figure 3. (A) A resistant proximal cap is crossed with a combination of a Confienza Pro 12 (Asahi Intecc) and Turnpike Gold (Teleflex). (B) The stiff wire is removed and swapped out for a low penetration force, polymer-jacketed knuckle wire. (C) The proximal cap is dilated with a 2.5mm balloon to facilitate the introduction of a Trapliner (Teleflex). (D) A CrossBoss is then used to complete a controlled dissection to the landing zone. (E) The Trapliner facilitates efficient delivery of a Stingray balloon to allow controlled re-entry to occur. (F) Final result after stent deployment and optimization.

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  Figure 6 Correct angiographic orientation of the Stingray balloon.

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  Figure 7 Examples of different disease burdens at the landing zone. The most rightward example is often amenable to re-entry with the Stingray wire, whereas many experienced operators are now using high penetration force wires for the scenario on the left.

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