Chronic total occlusion (CTO) of coronary artery remains the Achilles heel of the interventional cardiologist and is present in a significant proportion of referrals for coronary artery bypass graft surgery (CABG); however, with the development and standardization of modern CTO recanalization techniques, it has been able to achieve excellent success while coping with lesions of increasing complexity. Nevertheless, failure to recanalize despite the development of new techniques still remains one of the challenges in the field of interventional cardiology. Spontaneous recanalization has been described in nonocclusive coronary artery dissections in detail; none has addressed the possibility of spontaneous recanalization after failed percutaneous coronary intervention (PCI). We report a case of spontaneous but delayed recanalization of CTO of left anterior descending artery 3 years after attempted but failed revascularization during PCI

Bikkina, Mahesh

Guragai, Nirmal

Patel, Hiten

Rampal, Upamanyu

Shamoon, Fayez

Vasudev, Rahul

Virk, Hartaj

English

The Touro College and University System

Touro Scholar NYMC Faculty Publications Faculty 8-1-2018 Delayed Spontaneous Recanalization of Chronic Total Occlusion of Left Anterior Descending Artery after Attempted but Failed Revascularization During Percutaneous Coronary Intervention Nirmal Guragai Upamanyu Rampal Rahul Vasudev New York Medical College Hiten Patel New York Medical College Mahesh Bikkina New York Medical College See next page for additional authors Follow this and additional works at: https://touroscholar.touro.edu/nymc_fac_pubs  Part of the Medicine and Health Sciences Commons Recommended Citation Guragai, N., Rampal, U., Vasudev, R., Patel, H., Bikkina, M., Shamoon, F., & Virk, H. (2018). Delayed Spontaneous Recanalization of Chronic Total Occlusion of Left Anterior Descending Artery after Attempted but Failed Revascularization During Percutaneous Coronary Intervention. Journal of Community Hospital Internal Medicine Perspectives, 8 (4), 223-226. https://doi.org/10.1080/20009666.2018.1490140 This Article is brought to you for free and open access by the Faculty at Touro Scholar. It has been accepted for inclusion in NYMC Faculty Publications by an authorized administrator of Touro Scholar. For more information, please contact daloia@nymc.edu. Authors Nirmal Guragai, Upamanyu Rampal, Rahul Vasudev, Hiten Patel, Mahesh Bikkina, Fayez Shamoon, and Hartaj Virk This article is available at Touro Scholar: https://touroscholar.touro.edu/nymc_fac_pubs/1273 Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=zjch20Journal of Community Hospital Internal MedicinePerspectivesISSN: (Print) 2000-9666 (Online) Journal homepage: http://www.tandfonline.com/loi/zjch20Delayed spontaneous recanalization of chronictotal occlusion of left anterior descending arteryafter attempted but failed revascularizationduring percutaneous coronary interventionNirmal Guragai, Upamanyu Rampal, Rahul Vasudev, Hiten Patel, HashitaDiana Manohar, Pragya Bhandari, Mahesh Bikkina, Fayez Shamoon & HartajVirkTo cite this article: Nirmal Guragai, Upamanyu Rampal, Rahul Vasudev, Hiten Patel,Hashita Diana Manohar, Pragya Bhandari, Mahesh Bikkina, Fayez Shamoon & HartajVirk (2018) Delayed spontaneous recanalization of chronic total occlusion of left anteriordescending artery after attempted but failed revascularization during percutaneous coronaryintervention, Journal of Community Hospital Internal Medicine Perspectives, 8:4, 223-226, DOI:10.1080/20009666.2018.1490140To link to this article:  https://doi.org/10.1080/20009666.2018.1490140© 2018 The Author(s). Published by InformaUK Limited, trading as Taylor & FrancisGroup on behalf of Greater BaltimoreMedical Center.Published online: 23 Aug 2018.Submit your article to this journal Article views: 42View Crossmark dataCASE REPORTDelayed spontaneous recanalization of chronic total occlusion of left anteriordescending artery after attempted but failed revascularization duringpercutaneous coronary interventionNirmal Guragai a, Upamanyu Rampala, Rahul Vasudeva, Hiten Patela, Hashita Diana Manoharb,Pragya Bhandaric, Mahesh Bikkinaa, Fayez Shamoona and Hartaj VirkaaDepartment of Cardiology, New York Medical College at St Joseph’s Regional Medical Center, Paterson, NJ, USA; bResearch Intern,University of Louisville, Louisville, KY, USA; cDepartment of Internal Medicine, Manipal College of Medical Sciences, Pokhara, NepalABSTRACTChronic total occlusion (CTO) of coronary artery remains the Achilles heel of the interven-tional cardiologist and is present in a significant proportion of referrals for coronary arterybypass graft surgery (CABG); however, with the development and standardization of modernCTO recanalization techniques, it has been able to achieve excellent success while copingwith lesions of increasing complexity. Nevertheless, failure to recanalize despite the develop-ment of new techniques still remains one of the challenges in the field of interventionalcardiology. Spontaneous recanalization has been described in nonocclusive coronary arterydissections in detail; none has addressed the possibility of spontaneous recanalization afterfailed percutaneous coronary intervention (PCI). We report a case of spontaneous but delayedrecanalization of CTO of left anterior descending artery 3 years after attempted but failedrevascularization during PCI.ARTICLE HISTORYReceived 24 March 2018Accepted 12 June 2018KEYWORDSChronic total occlusion;delayed spontaneousrecanalization;revascularization;percutaneous coronaryintervention;microdissection1. IntroductionA chronic total occlusion (CTO) is defined as an angio-graphically documented or clinically suspected com-plete interruption of antegrade coronary flow(Thrombolysis In Myocardial Infarction-TIMI – 0flow) of at least 3 months durations [1]. CTOs are acommon finding during routine coronary angiographyand the prevalence varies from 18% to 52% [2]. CTOstypically have collateralization of the distal vessel oncoronary angiography, but these collaterals may notprovide sufficient blood flow to the myocardial bed,resulting in ischemia and anginal symptoms. Patientswho remain symptomatic with demonstration of viablemyocardium despite maximal medical therapy can beconsidered for revascularization. The development andstandardization of modern CTO recanalization techni-ques during percutaneous coronary intervention (PCI)has lead to success rates far beyond 90% despiteencountering lesions of greater complexity [3]. Despitethese recent advances only 10% of all CTOs have beentreated with percutaneous techniques over a long per-iod of time, with the majority of patients primarilymanaged medically or referred for coronary arterybypass graft surgery (CABG) [4].Over a long period of time CTO-PCI complicationsrates remained <2%, which is comparable to complica-tion rates for non-CTO interventions [5]. This rate seemsto hold steady even in the contemporary era of advancedtechniques and new dedicated guidewires. However, thedevelopment of novel techniques such as antegrade dis-section reentry and retrograde approach have overallimproved success in even inmore complex lesion subsetssuch as those with ambiguous proximal cap, poor distaltargets, and long occlusions. With these recent advancesin the technique and device technology, success rateshave improved to 80–90% in specialized centers [6].Nevertheless, failure to recanalize despite the develop-ment of new techniques still remains one of the chal-lenges in the field of interventional cardiology. Usually,symptomatic patients who have undergone a failed PCIof a CTO would be considered candidates for CABG.However, it is extremely rare to see spontaneous recana-lization after failed PCI [7]. This spontaneous recanaliza-tion has been well documented in nonocclusive coronaryartery dissections in detail; none has addressed the pos-sibility of spontaneous recanalization after guidewireinduced microdissections. Although its true incidence isunknown, we report an interesting case of late sponta-neous revascularization of CTO of left anterior descend-ing (LAD) artery after failed revascularizationduring PCI.2. Case presentationA 76 years old male with past medical history of end-stage renal disease on hemodialysis, hypertension,CONTACT Nirmal Guragai nirmalguragai@yahoo.com St Joseph’s Regional Medical Center, Paterson, NJ 07503, USAJOURNAL OF COMMUNITY HOSPITAL INTERNAL MEDICINE PERSPECTIVES2018, VOL. 8, NO. 4, 223–226https://doi.org/10.1080/20009666.2018.1490140© 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of Greater Baltimore Medical Center.This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/),which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.dyslipidemia, anemia of chronic disease, and obstruc-tive sleep apnea presented to the office for evaluationof typical exertional chest pain. On examination, hisvitals were within normal limits. Physical examina-tion was also grossly unremarkable. He underwentcoronary angiography due to the typical nature ofhis symptoms and high pretest probability for coron-ary artery disease. Coronary angiography showed a100% stenosis of mid-LAD artery suggestive of CTO.Subsequently he underwent a Thallium nuclear via-bility study which revealed viable myocardium in theLAD artery territory. He was thus brought back tothe cardiac catheterization laboratory for revascular-ization. Initially, a 7F XB 3.5 guiding catheter wasused to intubate the vessel. 014 HT Balance MiddleWeight Universal 300-cm wire was used in an unsuc-cessful attempt to cross the lesion. An antegrade wireescalating using Fielder FC wire with Finecross®microcatheter was attempted. However, the wirecould not be crossed across the full length of theCTO. Following attempted intervention, there wasstill a 100% residual stenosis, and the procedure wasaborted (Figure 1(A–D)). It was decided to managethe patient with optimal medications includingaspirin, statin, lisinopril, and nitrates. The patienthad a fair clinical outcome and did not report anyexertional chest pain for the next few years. Threeyears later, the patient presented to the clinic forFigure 1. Panel A, C, and E with right anterior oblique projection showing mid left anterior descending (LAD) artery chronic totalocclusion (CTO) stump, unable to cross XYZ wire into true lumen of LAD artery distal to CTO stump, and spontaneousrecanalization after 3 years, respectively. Panel B, D, and F with anterio-posterior cranial view showing attempted antegradecrossing of CTO with XYZ wire, unchanged LAD artery stump CTO after attempted antegrade wire crossing and spontaneouslyrecanalized LAD artery 3 years after attempted wire crossing, respectively. (LCx: Left Circumflex).224 N. GURAGAI ET AL.preoperative evaluation for creation of arteriovenousfistula for dialysis. Echocardiography demonstratedsevere pulmonary hypertension and eventually thepatient underwent repeat coronary angiography thatrevealed spontaneous recananlization of the priorCTO of the mid-LAD artery with a 60% stenosis atthe site of prior CTO (Figure 1(E,F)). The lesion wasmoderately calcified. Hemodynamic assessment ofthis lesion was performed using Fractional Flowreserve and was calculated at 0.81, suggestive ofnon-hemodynamically significant stenosis. Thus, thepreviously noted CTO of mid-LAD artery was nolonger present, and there was a spontaneous recana-lization of the totally occluded artery.3. DiscussionHere, we have reported an interesting case of sponta-neous recanalization of a macrodissection of LADartery following attempted guidewire crossing of aCTO. CTOs are routinely encountered during coron-ary angiography, but subsequent revascularizationrates are low. With the advent of newer techniquesand interventional devices, CTO is being intervenedupon with increasing frequency [8,9]. New devicesand therapies continue to be developed to improveCTO-PCI procedural success despite which there areabout 10% chance of failure and about 1% risk formajor complications of death, myocardial infarction,tamponade, and contrast-induced nephropathy [5].The typical pathological finding in a occluded seg-ment would show fibrous tissue, atheroma with orwithout calcification, vascular tissue, and infiltrates oflymphocytes [10]. The basic pathological feature of aCTO consists firstly of a proximal cap with fibrotic orcalcified constituents and with either a tapering ornon-tapering morphology. Occlusions with taperedcap are shorter and are less likely to have sidebranches at the proximal cap (1/5 versus 4/5 fornon-tapered occlusions). The tissue content oftapered occlusions consists characteristically of loosefibrous tissue, with prominent neovascularization.There may be multiple small non-functional recana-lized neo-microchannels throughout the occlusionsor one central lumen for recanalization connectingthe proximal and distal lumens [5], giving the falseimpression of a functionally sub-occlusive lesion.Careful examination of the occlusion in multipleviews can delineate the position of these collateralsoutside the vessel architecture.Failure to revascularize depends upon several fac-tors. There are two important factors that relate tothe feasibility of crossing the occlusion with a wire.First is plaque composition, which has a straightfor-ward relationship with lesion age, with gradual repla-cement of cholesterol and foam cells with fibrous andcalcific material. The other factor is extent of vesselrecanalization, which is associated with loose fibroustissue, less resistance to wire passage and does notseem to have a clear relationship with age nor lesionlength.The key aspect determining the success of revas-cularization in CTO PCI is the operator to manipu-late the guidewire across the occluded segment fromthe proximal lumen to distal lumen. Frequently, theCTO segments have a highly resistant proximal end,at the point of transition from patent vessel to theoccluded proximal cap, and these segments are oftenheavily calcified. An analogous distal cap is alsorecognized as a point of difficult re-entry into thedistal true lumen, but less so than the proximal cap.Neovascularization channels are approximately 200microns in diameter, which is slightly smaller thanthe tip of a specialized CTO wires (such as fielder XT/FC, Asahi Intecc, Japan).We postulate that the use of the wire to open thelesion must have lead to the opening of microchannelswithin the thrombus resulting in the opening of occludedvessel as well as the enzymatic degradation of connectivetissue by release of collagenase during CTO PCI, whichcould have enabled rapid and reliable wire crossing.4. ConclusionPercutaneous revascularization of CTO is often com-plicated by the inability to cross or dilate the lesion,as well as a high incidence of restenosis and reocclu-sion. Although spontaneous coronary recanalizationcan occur in patients undergoing catheterization foracute myocardial infarction or failed PCI due tocoronary dissection, it is a rare event in CTOs, parti-cularly in native coronary arteries. In some instances,just manipulation with wire during PCI can lead tomacrodissection and spontaneous opening of thechronically occluded lesion.Disclosure statementNo potential conflict of interest was reported by theauthors.ORCIDNirmal Guragai http://orcid.org/0000-0002-6477-7789References[1] Sianos G, Werner GS, Galassi AR, et al. Recanalisationof chronic total coronary occlusions: 2012 consensusdocument from the EuroCTO club. Euro Interv.2012;8(1):139–145.[2] Fefer P, Knudtson ML, Cheema AN, et al. Currentperspectives on coronary chronic total occlusions: theCanadian multicenter chronic total occlusions regis-try. J Am Coll Cardiol. 2012;59(11):991–997.JOURNAL OF COMMUNITY HOSPITAL INTERNAL MEDICINE PERSPECTIVES 225[3] Sianos G, Konstantinidis NV, Di Mario C, et al.Theory and practical based approach to chronic totalocclusions. BMC Cardiovasc Disord. 2016 Feb 9;16:33.[4] Sathananthan J1, Džavík V. Coronary intervention forchronic total occlusion: current indications and futuredirections. Coron Artery Dis. 2017 Aug;28(5):426–436.[5] Rathore S, Matsuo H, Terashima M, et al. Proceduraland in-hospital outcomes after percutaneous coronaryintervention for chronic total occlusions of coronaryarteries 2002 to 2008: impact of novel guidewire tech-niques. JACC Cardiovasc Interv. 2009;2(6):489–497.[6] Shan P. Management of coronary chronic total occlu-sion Pinak B. Circulation. 2011;123:1780–1784.[7] Özer C, Özeke Ö, Güngör M, et al. Late spontaneousrecanalization of in-stent chronic total occlusionfacilitating successful percutaneous coronary revascu-larization of the right coronary artery: case report.TurkiyeKlinikleri J Cardiovasc Sci. 2012;24(3):346–348.[8] Stone GW, Colombo A, Teirstein PS, et al.Percutaneous recanalization of chronically occludedcoronary arteries: procedural techniques, devices, andresults. Catheter Cardiovasc Interv. 2005;66(2):217–236.[9] Thompson C. Techniques for percutaneous revascu-larization of coronary CTO; Necessary skillsets for ahybrid approach to CTO PCI. InterventionalCardiology Clinics. 2012;1(3):349–353.[10] Irving J, Pathophysiology CTO. How does this affectmanagement? Curr Cardiol Rev. 2014 May;10(2):99–107.226 N. GURAGAI ET AL.

Delayed Spontaneous Recanalization of Chronic Total Occlusion of Left Anterior Descending Artery after Attempted but Failed Revascularization During Percutaneous Coronary Intervention

https://touroscholar.touro.edu/cgi/viewcontent.cgi?article=2155&amp;context=nymc_fac_pubs

Delayed Spontaneous Recanalization of Chronic Total Occlusion of Left Anterior Descending Artery after Attempted but Failed Revascularization During Percutaneous Coronary Intervention

Abstract

Similar works

Full text

Available Versions

The Touro College and University System