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New CTO Recanalization Method "Anchor-Balloon Technique" in Patients with Heavily Calcified CTO Lesion

- Operator: Etsuo Tsuchikane, MD

Clinical Presentation

A 69-year old man was admitted due to aggravated chest pain for 4 months. His coronary risk factors were hypertension and diabetes. Treadmill exercise test was positive. Echocardiography showed akinesia of inferoposterior wall with normal LV function. Previous attempt to cross the CTO lesion was failed one month ago.

Baseline Coronary Angiography

1. Left coronary angiogram showed diffuse 30-40 % narrowing of mid to distal LAD with heavy calcification (Figure 1, Figure 2).
2. Right coronary angiogram showed heavy calcification of mid to distal RCA with discrete subtotal occlusion of mid RCA with TIMI 3 flow and collateral supply from LAD (Figure 3, Figure 4).

Procedure

RCA was engaged with 8F JR3.5 guiding catheter and left coronary artery was engaged with 6F JL4. At first, 0.014 inch soft guidewire (Neos, Asahi, Japan) was entered into the RV branch and 0.014 inch Fielder guidewire (Neos, Asahi, Japan) was antegradely advanced with a 0.018 inch microcatheter (Prowler plus; Cordis, Johnson & Johnson) and failed to pass through the entry point (Figure 5). Antegrade wiring with Miracle 3 (Neos, Asahi, Japan) was failed again, but Conquest pro GW (Neos, Asahi, Japan) was smoothly advanced through the target lesion (Figure 6). After wiring, Conquest pro GW was exchanged to Neos soft guidewire using extension wire. And then, Tornus (Asahi intec, Japan) was tried to cross lesion, which failed to pass the lesion. Therefore, RV branch was dilated with balloon with 4 atm pressure (2.5mm 15mm Ryujin, Terumo, Japan) and used as anchor-balloon (Figure 7). And then, predilation of mid RCA was achieved with a Ryujin 1.25 15 mm by 20 atm (1.5mm) and Ryujin 2.5 15 mm balloon by 18 atm sequentially and 3.0 10 mm cutting balloon inflation by 8 atm (Figure 8, Figure 9, Figure 10, Figure 11). After cutting balloon inflation, a 3.0 33 mm Cypher stent was positioned at mid RCA and deployed by 14 atm (Figure 12). The RV branch was jailed, but rewiring was failed. And then, additional balloon was performed with a 3.0 13 mm Fortis at 18atm (3.11mm) (Figure 13, Figure 14). Final angiogram showed a well-expanded stents without residual narrowing (Figure 15, Figure 16).

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