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A Case-Based Illustration of a Dual-Operator, Dual Microcatheter Technique for Side Branch Wiring
CARREV-01674; No of Pages 5 Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring Allison B. Hall, Iosif Xenogiannis, M. Nicholas Burke, Emmanouil S. Brilakis ⁎ Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
a r t i c l e
i n f o
Article history: Received 14 July 2019 Received in revised form 14 August 2019 Accepted 14 August 2019 Available online xxxx Keywords: Complex coronary intervention Dual-lumen microcatheter Side branch wiring
a b s t r a c t Wiring a side branch through a dual lumen microcatheter is typically performed in sequential fashion: the microcatheter position is modified, followed by wiring attempts, all performed by a single operator. We describe a dual operator technique, in which positioning of the dual lumen microcatheter and guidewire advancement are performed simultaneously. This method can be used for particularly challenging wiring scenarios. We provide two case examples illustrating how this technique could facilitate the success and efficiency of side branch wiring. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous coronary interventions (PCI) often require directing a guidewire through tortuosity, into a side branch, or parallel to a previously placed guidewire (parallel wiring), which can be challenging. Guidewire maneuverability can be improved with use of a microcatheter. Dual lumen microcatheters, such as the Twinpass and TwinPass Torque (Teleflex, Wayne, PA, USA) can facilitate directing a second guidewire into a side branch, while another wire remains within the main vessel. Forward or backward movement of the dual lumen microcatheter can facilitate guidewire advancement to the desired location, and is usually performed in a sequential manner: microcatheter movement first, followed by guidewire advancement, followed by microcatheter movement, etc. We describe two cases that illustrate a two-operator technique that combines real-time, dynamic adjustment of the dual lumen microcatheter position by one operator, with simultaneous wiring efforts by a second operator. While a skilled single operator can have excellent success in difficult wiring using a dual lumen microcatheter as an individual, the dual operator, dual microcatheter technique could further improve the efficiency and success of side branch wiring in particularly difficult cases. 2. Case 1 A 63-year-old man with a history of hypertension, dyslipidemia, type 2 diabetes mellitus and chronic renal impairment, presented
⁎ Corresponding author at: Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407, USA. E-mail address: [email protected] (E.S. Brilakis).
with unstable angina. He had undergone coronary artery bypass graft surgery (CABG) 15 years earlier, with a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) and a sequential saphenous vein graft (SVG) to the first and second obtuse marginal branch (OM1 and OM2). Coronary angiography demonstrated a diffusely diseased LAD after the LIMA insertion. The initial portion of the sequential SVG to OM1 and OM2 was occluded and OM2 was filling via the since-stented left circumflex (LCx). OM1 was occluded and was filling through the patent sequential segment of the SVG between OM 1 and OM2, but this sequential portion had a severe stenosis and TIMI 2 flow (Fig. 1, Panel A). There was also a severe ostial LCx lesion. Attempts to wire through the SVG sequential segment resulted in worsening flow through the graft with transient severe chest pain. The procedure was stopped and the patient underwent emergent computed tomography coronary angiography (CTA) that demonstrated that the “OM1” was actually the ramus branch (Figs. 1, Panel A & 2). The occlusion was approximately 20 mm in length, with limited contrast opacification proximally and a small lateral branch which was patent, near the proximal cap. The patient returned later on the same day for PCI of the ramus CTO. A Corsair (Asahi Intecc, Nagoya, Japan) microcatheter was advanced to the proximal cap over a Sion Blue (Asahi Intecc) wire. Antegrade wiring with a Pilot 200 (Abbott Vascular, Santa Rosa California, USA), a Gaia Second (Asahi Intecc) and a Fielder XT-A (Asahi Intecc) wire failed. A Gaia Third (Asahi Intecc) wire subsequently crossed, but kept entering into the SVG sequential portion and could not be redirected into the ramus (Fig. 1, Panel A). The Gaia Third wire was exchanged for a Sion Blue wire (Asahi Intecc) and a Twinpass Torque dual-lumen microcatheter (Teleflex, Wayne, PA) was advanced over this wire, followed by attempts to advance a second Sion Blue guidewire into
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
2
A.B. Hall et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Fig. 1. Coronary angiography demonstrating near complete occlusion of a sequential saphenous vein graft (SVG) segment between the first and second obtuse marginal branches (OM1 and OM2) (Panel A, X). The OM1 origin was unclear (Panel A, *). Emergency coronary computed tomography angiography demonstrated that OM1 was actually the ramus branch that had a chronic total occlusion (Panel A, white arrow). Antegrade wire escalation attempts using a Corsair microcatheter and ultimately a Gaia Third guidewire, resulted in crossing into the SVG sequential segment (Panel A, black arrow). Using the dual operator, dual lumen microcatheter technique, a Sion Blue guidewire was advanced into the ramus (Panel B & C, black arrows). After stenting antegrade flow was restored into the ramus (Panel C).
the ramus via the over-the-wire exit port. However, the wire continued to enter into the SVG connecting segment. Since a single operator could not readily succeed in redirecting the wire with the dual lumen microcatheter, using the dual operator, dual microcatheter technique (one operator was advancing or withdrawing the Twinpass microcatheter, while the other operator was probing with the Sion Blue guidewire through the Twinpass over-the-wire lumen) the guidewire was successfully advanced into the ramus followed by stenting and restoration of TIMI 3 antegrade flow (Fig. 1, Panels B & C).
3. Case 2 A 69-year-old man with a history of dyslipidemia, obstructive sleep apnea, deep venous thrombosis and ischemic cardiomyopathy, presented with unstable angina. He had undergone multiple prior PCIs, including stenting of the diagonal and proximal LAD 8 years prior, stenting of the OM1 2 years prior, and stenting of the left main 1 year prior. A few months earlier, he underwent a failed PCI attempt of a severe ostial LCx lesion that was complicated by stent loss, requiring
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
A.B. Hall et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
3
advanced through the CTO over the Pilot 200, which was exchanged for a workhorse guidewire. The OM1 was successfully stented using the Double Kiss-Crush technique and a 6 French Guideliner (Teleflex) for support (Fig. 3, Panel C). 4. Discussion
Fig. 2. Coronary computed tomography angiography image, clarifying anatomy of the chronic total occlusion (CTO) vessel: what was described as a first obtuse marginal was a ramus intermedius branch (*). The CTO segment (yellow arrow), as well as the surrounding anatomy including a small branch off the ramus (+), the grafted left anterior descending artery (LAD) (•) and the diseased saphenous vein graft (SVG) skip portion (x) are delineated. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
emergent CABG. At CABG, in addition to retrieval of the lost stent, the LIMA was grafted to OM1 and a SVG was grafted to the LAD. Coronary angiography demonstrated occlusion of the SVG to the LAD and a 90% distal anastomotic lesion in the LIMA graft. The ostial LCx was subtotally occluded and the proximal LAD had a significant stenosis (Fig. 3, Panel A). PCI of the LIMA-OM1 carried high risk for compromising flow to the LCx territory. Therefore, plans were made to perform PCI of the subtotal occlusion of the ostial circumflex. The left main was engaged with an 8 French EBU 3.75 guide catheter (Medtronic, Inc., Minneapolis, MN). A Supercross 120 (Teleflex) angled microcatheter was advanced to the circumflex ostium, followed by antegrade wire escalation. A Fielder FC guidewire (Asahi Intecc) failed to cross, but a Pilot 200 wire advanced distally. However, injections through the LIMA graft indicated subintimal guidewire position (Fig. 3, Panel A). A brief attempt at retrograde crossing through the LIMA to the OM failed due to inability to advance the guidewire through the distal anastomosis. The subintimally positioned wire was left in place as a marker for an attempt at parallel wiring and we then inserted a knuckled Fielder FC wire into the LAD and advanced a Twinpass Torque, dual-lumen microcatheter to the proximal cap (Fig. 3, Panel B).The dual-operator Twinpass technique succeeded in advancing a Pilot 200 wire into the distal true lumen (Fig. 3, Panel C), while single operator attempts with the device had failed. A Caravel (Asahi Intecc) microcatheter was
Our cases illustrate how the dual operator, dual lumen microcatheter technique can facilitate side branch wiring during complex PCI. Typically, guidewire manipulations through a dual lumen microcatheter occur in a sequential manner: guidewire advancement – dual lumen repositioning – guidewire advancement – dual lumen repositioning, etc. While a skilled individual operator can perform these steps smoothly, the two operator, dual lumen microcatheter technique, further enhances simultaneous/dynamic performance of both steps with real-time fine adjustments: one operator is moving the dual lumen microcatheter, while the other is advancing the guidewire (Fig. 4). This is analogous to crossing the aortic valve in patients with aortic stenosis by advancing or retracting an AL1 catheter, while simultaneously advancing and withdrawing an 0.035 guidewire. The technique requires coordination between the two operators: both must first visually focus on the area of interest for wire direction upon the screen. The dual lumen MC is then positioned in an initial promising position. Then, one operator watches carefully as the second operator attempts to advance the wire in the desired path and makes a judgement as to how to slightly adjust the dual lumen MC distally or proximally to potentially facilitate successful wiring as the other operator continues to attempt wiring almost constantly as the device is moved, albeit gently, so as to minimize vessel injury. Despite its advantages, this technique also has limitations: first it does require 2 operators, who may not be available in all catheterization laboratories and in all cases; second, it may be associated with risk for side branch injury during guidewire manipulations, particularly with less individual operator tactile feedback; therefore, soft, workhorse guidewires should ideally be used through the over-the-wire dual microcatheter lumen. The first case also illustrates how CT angiography can help clarify proximal cap ambiguity before performing CTO PCI. CT angiography clarified that the target vessel was actually the ramus and not the OM1 (Fig. 2), facilitating the eventual success of the procedure. Performance of diagnostic angiography, CT angiography, and CTO PCI during the same day may result in high contrast dose (369 mL were used in our patient for all procedures) and should, therefore, only be done, when staging of the procedure is not feasible. In summary, the dual operator, dual microcatheter technique can be an option that can further facilitate side branch wiring during challenging PCI cases. Funding None. Declaration of competing interest Dr. Hall: none. Dr. Xenogiannis: none. Dr. Burke: consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, Teleflex, Siemens and Medtronic; research support from Regeneron and Siemens. Shareholder: MHI Ventures.
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
4
A.B. Hall et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Fig. 3. Dual injection demonstrating a subtotal occlusion of the proximal circumflex (Panel A, white arrow) with the OM1 filling via a LIMA graft with an anastomotic stenosis (Panel A, x). Antegrade wiring escalation attempts using a SuperCross 120 microcatheter resulted in subintimal guidewire crossing (Panel A, *). An operator advanced and withdrew a TwinPass Torque microcatheter over the LAD guidewire, while a second operator advanced a Pilot 200 guidewire into the mid circumflex, as confirmed by injection through the LIMA-OM1 graft (Panels B & C, white arrows). After stenting of the distal left main bifurcation using the DK crush technique, and excellent final result was achieved (Panel C).
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
A.B. Hall et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Fig. 4. Illustration of the dual-operator, dual microcatheter technique. The first operator (on the left of the image) advances and retracts the Twinpass Torque microcatheter, while the second operator (on the right of the image) advances and withdraws a guidewire through the over-the-wire lumen of the Twinpass Torque microcatheter, under fluoroscopic guidance.
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
5
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring Allison B. Hall, Iosif Xenogiannis, M. Nicholas Burke, Emmanouil S. Brilakis ⁎ Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
a r t i c l e
i n f o
Article history: Received 14 July 2019 Received in revised form 14 August 2019 Accepted 14 August 2019 Available online xxxx Keywords: Complex coronary intervention Dual-lumen microcatheter Side branch wiring
a b s t r a c t Wiring a side branch through a dual lumen microcatheter is typically performed in sequential fashion: the microcatheter position is modified, followed by wiring attempts, all performed by a single operator. We describe a dual operator technique, in which positioning of the dual lumen microcatheter and guidewire advancement are performed simultaneously. This method can be used for particularly challenging wiring scenarios. We provide two case examples illustrating how this technique could facilitate the success and efficiency of side branch wiring. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous coronary interventions (PCI) often require directing a guidewire through tortuosity, into a side branch, or parallel to a previously placed guidewire (parallel wiring), which can be challenging. Guidewire maneuverability can be improved with use of a microcatheter. Dual lumen microcatheters, such as the Twinpass and TwinPass Torque (Teleflex, Wayne, PA, USA) can facilitate directing a second guidewire into a side branch, while another wire remains within the main vessel. Forward or backward movement of the dual lumen microcatheter can facilitate guidewire advancement to the desired location, and is usually performed in a sequential manner: microcatheter movement first, followed by guidewire advancement, followed by microcatheter movement, etc. We describe two cases that illustrate a two-operator technique that combines real-time, dynamic adjustment of the dual lumen microcatheter position by one operator, with simultaneous wiring efforts by a second operator. While a skilled single operator can have excellent success in difficult wiring using a dual lumen microcatheter as an individual, the dual operator, dual microcatheter technique could further improve the efficiency and success of side branch wiring in particularly difficult cases. 2. Case 1 A 63-year-old man with a history of hypertension, dyslipidemia, type 2 diabetes mellitus and chronic renal impairment, presented
⁎ Corresponding author at: Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407, USA. E-mail address: [email protected] (E.S. Brilakis).
with unstable angina. He had undergone coronary artery bypass graft surgery (CABG) 15 years earlier, with a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) and a sequential saphenous vein graft (SVG) to the first and second obtuse marginal branch (OM1 and OM2). Coronary angiography demonstrated a diffusely diseased LAD after the LIMA insertion. The initial portion of the sequential SVG to OM1 and OM2 was occluded and OM2 was filling via the since-stented left circumflex (LCx). OM1 was occluded and was filling through the patent sequential segment of the SVG between OM 1 and OM2, but this sequential portion had a severe stenosis and TIMI 2 flow (Fig. 1, Panel A). There was also a severe ostial LCx lesion. Attempts to wire through the SVG sequential segment resulted in worsening flow through the graft with transient severe chest pain. The procedure was stopped and the patient underwent emergent computed tomography coronary angiography (CTA) that demonstrated that the “OM1” was actually the ramus branch (Figs. 1, Panel A & 2). The occlusion was approximately 20 mm in length, with limited contrast opacification proximally and a small lateral branch which was patent, near the proximal cap. The patient returned later on the same day for PCI of the ramus CTO. A Corsair (Asahi Intecc, Nagoya, Japan) microcatheter was advanced to the proximal cap over a Sion Blue (Asahi Intecc) wire. Antegrade wiring with a Pilot 200 (Abbott Vascular, Santa Rosa California, USA), a Gaia Second (Asahi Intecc) and a Fielder XT-A (Asahi Intecc) wire failed. A Gaia Third (Asahi Intecc) wire subsequently crossed, but kept entering into the SVG sequential portion and could not be redirected into the ramus (Fig. 1, Panel A). The Gaia Third wire was exchanged for a Sion Blue wire (Asahi Intecc) and a Twinpass Torque dual-lumen microcatheter (Teleflex, Wayne, PA) was advanced over this wire, followed by attempts to advance a second Sion Blue guidewire into
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
2
A.B. Hall et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Fig. 1. Coronary angiography demonstrating near complete occlusion of a sequential saphenous vein graft (SVG) segment between the first and second obtuse marginal branches (OM1 and OM2) (Panel A, X). The OM1 origin was unclear (Panel A, *). Emergency coronary computed tomography angiography demonstrated that OM1 was actually the ramus branch that had a chronic total occlusion (Panel A, white arrow). Antegrade wire escalation attempts using a Corsair microcatheter and ultimately a Gaia Third guidewire, resulted in crossing into the SVG sequential segment (Panel A, black arrow). Using the dual operator, dual lumen microcatheter technique, a Sion Blue guidewire was advanced into the ramus (Panel B & C, black arrows). After stenting antegrade flow was restored into the ramus (Panel C).
the ramus via the over-the-wire exit port. However, the wire continued to enter into the SVG connecting segment. Since a single operator could not readily succeed in redirecting the wire with the dual lumen microcatheter, using the dual operator, dual microcatheter technique (one operator was advancing or withdrawing the Twinpass microcatheter, while the other operator was probing with the Sion Blue guidewire through the Twinpass over-the-wire lumen) the guidewire was successfully advanced into the ramus followed by stenting and restoration of TIMI 3 antegrade flow (Fig. 1, Panels B & C).
3. Case 2 A 69-year-old man with a history of dyslipidemia, obstructive sleep apnea, deep venous thrombosis and ischemic cardiomyopathy, presented with unstable angina. He had undergone multiple prior PCIs, including stenting of the diagonal and proximal LAD 8 years prior, stenting of the OM1 2 years prior, and stenting of the left main 1 year prior. A few months earlier, he underwent a failed PCI attempt of a severe ostial LCx lesion that was complicated by stent loss, requiring
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
A.B. Hall et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
3
advanced through the CTO over the Pilot 200, which was exchanged for a workhorse guidewire. The OM1 was successfully stented using the Double Kiss-Crush technique and a 6 French Guideliner (Teleflex) for support (Fig. 3, Panel C). 4. Discussion
Fig. 2. Coronary computed tomography angiography image, clarifying anatomy of the chronic total occlusion (CTO) vessel: what was described as a first obtuse marginal was a ramus intermedius branch (*). The CTO segment (yellow arrow), as well as the surrounding anatomy including a small branch off the ramus (+), the grafted left anterior descending artery (LAD) (•) and the diseased saphenous vein graft (SVG) skip portion (x) are delineated. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
emergent CABG. At CABG, in addition to retrieval of the lost stent, the LIMA was grafted to OM1 and a SVG was grafted to the LAD. Coronary angiography demonstrated occlusion of the SVG to the LAD and a 90% distal anastomotic lesion in the LIMA graft. The ostial LCx was subtotally occluded and the proximal LAD had a significant stenosis (Fig. 3, Panel A). PCI of the LIMA-OM1 carried high risk for compromising flow to the LCx territory. Therefore, plans were made to perform PCI of the subtotal occlusion of the ostial circumflex. The left main was engaged with an 8 French EBU 3.75 guide catheter (Medtronic, Inc., Minneapolis, MN). A Supercross 120 (Teleflex) angled microcatheter was advanced to the circumflex ostium, followed by antegrade wire escalation. A Fielder FC guidewire (Asahi Intecc) failed to cross, but a Pilot 200 wire advanced distally. However, injections through the LIMA graft indicated subintimal guidewire position (Fig. 3, Panel A). A brief attempt at retrograde crossing through the LIMA to the OM failed due to inability to advance the guidewire through the distal anastomosis. The subintimally positioned wire was left in place as a marker for an attempt at parallel wiring and we then inserted a knuckled Fielder FC wire into the LAD and advanced a Twinpass Torque, dual-lumen microcatheter to the proximal cap (Fig. 3, Panel B).The dual-operator Twinpass technique succeeded in advancing a Pilot 200 wire into the distal true lumen (Fig. 3, Panel C), while single operator attempts with the device had failed. A Caravel (Asahi Intecc) microcatheter was
Our cases illustrate how the dual operator, dual lumen microcatheter technique can facilitate side branch wiring during complex PCI. Typically, guidewire manipulations through a dual lumen microcatheter occur in a sequential manner: guidewire advancement – dual lumen repositioning – guidewire advancement – dual lumen repositioning, etc. While a skilled individual operator can perform these steps smoothly, the two operator, dual lumen microcatheter technique, further enhances simultaneous/dynamic performance of both steps with real-time fine adjustments: one operator is moving the dual lumen microcatheter, while the other is advancing the guidewire (Fig. 4). This is analogous to crossing the aortic valve in patients with aortic stenosis by advancing or retracting an AL1 catheter, while simultaneously advancing and withdrawing an 0.035 guidewire. The technique requires coordination between the two operators: both must first visually focus on the area of interest for wire direction upon the screen. The dual lumen MC is then positioned in an initial promising position. Then, one operator watches carefully as the second operator attempts to advance the wire in the desired path and makes a judgement as to how to slightly adjust the dual lumen MC distally or proximally to potentially facilitate successful wiring as the other operator continues to attempt wiring almost constantly as the device is moved, albeit gently, so as to minimize vessel injury. Despite its advantages, this technique also has limitations: first it does require 2 operators, who may not be available in all catheterization laboratories and in all cases; second, it may be associated with risk for side branch injury during guidewire manipulations, particularly with less individual operator tactile feedback; therefore, soft, workhorse guidewires should ideally be used through the over-the-wire dual microcatheter lumen. The first case also illustrates how CT angiography can help clarify proximal cap ambiguity before performing CTO PCI. CT angiography clarified that the target vessel was actually the ramus and not the OM1 (Fig. 2), facilitating the eventual success of the procedure. Performance of diagnostic angiography, CT angiography, and CTO PCI during the same day may result in high contrast dose (369 mL were used in our patient for all procedures) and should, therefore, only be done, when staging of the procedure is not feasible. In summary, the dual operator, dual microcatheter technique can be an option that can further facilitate side branch wiring during challenging PCI cases. Funding None. Declaration of competing interest Dr. Hall: none. Dr. Xenogiannis: none. Dr. Burke: consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr. Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, Teleflex, Siemens and Medtronic; research support from Regeneron and Siemens. Shareholder: MHI Ventures.
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
4
A.B. Hall et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Fig. 3. Dual injection demonstrating a subtotal occlusion of the proximal circumflex (Panel A, white arrow) with the OM1 filling via a LIMA graft with an anastomotic stenosis (Panel A, x). Antegrade wiring escalation attempts using a SuperCross 120 microcatheter resulted in subintimal guidewire crossing (Panel A, *). An operator advanced and withdrew a TwinPass Torque microcatheter over the LAD guidewire, while a second operator advanced a Pilot 200 guidewire into the mid circumflex, as confirmed by injection through the LIMA-OM1 graft (Panels B & C, white arrows). After stenting of the distal left main bifurcation using the DK crush technique, and excellent final result was achieved (Panel C).
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
A.B. Hall et al. / Cardiovascular Revascularization Medicine xxx (xxxx) xxx
Fig. 4. Illustration of the dual-operator, dual microcatheter technique. The first operator (on the left of the image) advances and retracts the Twinpass Torque microcatheter, while the second operator (on the right of the image) advances and withdraws a guidewire through the over-the-wire lumen of the Twinpass Torque microcatheter, under fluoroscopic guidance.
Please cite this article as: A.B. Hall, I. Xenogiannis, M.N. Burke, et al., A case-based illustration of a dual-operator, dual microcatheter technique for side branch wiring, Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2019.08.012
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