'Seesaw Balloon-Wire Cutting' and Chronic Total Occlusions
'Seesaw Balloon-Wire Cutting' and Chronic Total Occlusions
Clinical characteristics of all patients are summarized in Table 1. More patients were males, smokers, or had stable angina. Almost half of the patients were diabetic, hypertensive, or hyperlipidemic. About one-third of patients had prior myocardial infarction and 3 patients underwent a prior failed CTO PCI at local hospitals. Angiographic characteristics of all patients are presented in Table 2. There was a total of 21 target CTOs in 21 main vessels and one-third of the patients had diffuse triple-vessel disease. All vessels with a target CTO had collaterals supplying the distal vessel, including bridging, contralateral and/or ipsilateral circulation.
Technique features and procedural outcomes are shown in Table 3. The seesaw balloon-wire cutting technique was successfully performed in 17 patients (81.0%), leading to procedural success of their CTO lesions. The technique failed in 4 patients (19.0%) due to heavy circular calcification. Three of them had difficulty crossing a balloon through the lesion and 1 procedure was problematic while placing the second guidewire into the distal true lumen. As a bail-out procedure, a Rotablator was attempted in the 4 patients; 3 of these succeeded and 1 failed while exchanging the guidewire to the RotaWire. Hydrophilic stiff wires were selected as the second guidewire in 21 patients. The mean time of the successful seesaw balloon-wire cutting procedure was relatively short (21.9 ± 6.6 minutes). Total amount of contrast medium used during the PCI procedure was 256.7 ± 75.8 mL (range, 120–380 mL). No serious complications (coronary dissection, perforation, or death) were observed. Two cases of successful application of the seesaw balloon-wire cutting technique were illustrated in Figure 2.
(Enlarge Image)
Figure 2.
Examples of the use of "seesaw balloon-wire cutting" technique in "balloon-uncrossable" chronic total occlusions. (A) A total occlusion at the distal portion of the right coronary artery (RCA). (B) After the engagement of a 6 Fr AL1 ST guiding catheter into the RCA, a 1.2 × 6 mm balloon (MiniTREK; Abbott Vascular) failed to cross the occluded segment following the successful passage of a pilot 50 guidewire. (C) After performing the multi-wire plaque crushing procedure, the low-profile balloon still could not cross the occluded segment. (D, E) A stiffer hydrophilic pilot 150 guidewire was passed through the occlusion as the second guidewire, and then two 1.2 × 6 mm balloons (MiniTREK) were advanced over the two guidewires to perform the "seesaw balloon-wire cutting" technique. One of the two balloons ultimately passed through the occluded segment. (F) Final angiographic result after stent implantation. (G) A total occlusion at the proximal portion of the left anterior descending (LAD) coronary artery. (H) A 6 Fr BL3.0 guiding catheter was engaged into the left coronary artery (LCA). Following the successful passage of a Fielder XT guidewire, attempts to cross the occlusion with a 1.2 × 6 mm MiniTREK balloon failed. (I) Along with the Fielder XT, another Pilot 150 guidewire was manipulated into the distal true lumen of the LAD, but the low-profile balloon still could not cross the occluded segment. (J, K) Another 1.25 × 6 mm balloon (Sprinter Legend; Medtronic) was advanced to perform the seesaw balloon-wire cutting technique until one of the balloons passed through the occluded segment. (L) Final angiographic result after stent implantation.
Results
Clinical and Angiographic Characteristics
Clinical characteristics of all patients are summarized in Table 1. More patients were males, smokers, or had stable angina. Almost half of the patients were diabetic, hypertensive, or hyperlipidemic. About one-third of patients had prior myocardial infarction and 3 patients underwent a prior failed CTO PCI at local hospitals. Angiographic characteristics of all patients are presented in Table 2. There was a total of 21 target CTOs in 21 main vessels and one-third of the patients had diffuse triple-vessel disease. All vessels with a target CTO had collaterals supplying the distal vessel, including bridging, contralateral and/or ipsilateral circulation.
Technique Features and Procedural Outcomes
Technique features and procedural outcomes are shown in Table 3. The seesaw balloon-wire cutting technique was successfully performed in 17 patients (81.0%), leading to procedural success of their CTO lesions. The technique failed in 4 patients (19.0%) due to heavy circular calcification. Three of them had difficulty crossing a balloon through the lesion and 1 procedure was problematic while placing the second guidewire into the distal true lumen. As a bail-out procedure, a Rotablator was attempted in the 4 patients; 3 of these succeeded and 1 failed while exchanging the guidewire to the RotaWire. Hydrophilic stiff wires were selected as the second guidewire in 21 patients. The mean time of the successful seesaw balloon-wire cutting procedure was relatively short (21.9 ± 6.6 minutes). Total amount of contrast medium used during the PCI procedure was 256.7 ± 75.8 mL (range, 120–380 mL). No serious complications (coronary dissection, perforation, or death) were observed. Two cases of successful application of the seesaw balloon-wire cutting technique were illustrated in Figure 2.
(Enlarge Image)
Figure 2.
Examples of the use of "seesaw balloon-wire cutting" technique in "balloon-uncrossable" chronic total occlusions. (A) A total occlusion at the distal portion of the right coronary artery (RCA). (B) After the engagement of a 6 Fr AL1 ST guiding catheter into the RCA, a 1.2 × 6 mm balloon (MiniTREK; Abbott Vascular) failed to cross the occluded segment following the successful passage of a pilot 50 guidewire. (C) After performing the multi-wire plaque crushing procedure, the low-profile balloon still could not cross the occluded segment. (D, E) A stiffer hydrophilic pilot 150 guidewire was passed through the occlusion as the second guidewire, and then two 1.2 × 6 mm balloons (MiniTREK) were advanced over the two guidewires to perform the "seesaw balloon-wire cutting" technique. One of the two balloons ultimately passed through the occluded segment. (F) Final angiographic result after stent implantation. (G) A total occlusion at the proximal portion of the left anterior descending (LAD) coronary artery. (H) A 6 Fr BL3.0 guiding catheter was engaged into the left coronary artery (LCA). Following the successful passage of a Fielder XT guidewire, attempts to cross the occlusion with a 1.2 × 6 mm MiniTREK balloon failed. (I) Along with the Fielder XT, another Pilot 150 guidewire was manipulated into the distal true lumen of the LAD, but the low-profile balloon still could not cross the occluded segment. (J, K) Another 1.25 × 6 mm balloon (Sprinter Legend; Medtronic) was advanced to perform the seesaw balloon-wire cutting technique until one of the balloons passed through the occluded segment. (L) Final angiographic result after stent implantation.
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