4/3/2018 Subintimal Distal Anchor Technique for “Balloon-Uncrossable” Chronic Total Occlusions | Journal of Invasive Cardiology

Subintimal Distal Anchor Technique for “Balloon-

Uncrossable” Chronic Total Occlusions
Friday, 09/27/13 | 7791 reads

Author(s): Tesfaldet T. Michael, MD, MPH, Subhash Banerjee, MD, Emmanouil S. Brilakis, MD, PhD
Issue Number:
Volume 25 - Issue 10 - October, 2013
Abstract: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) presents unique
challenges and potential complications. The two most common failure modes are inability to cross the lesion
with a guidewire and failure to cross the CTO with a balloon after successful guidewire crossing (“balloon-
uncrossable” CTO). We present a creative solution to assist crossing of balloon-uncrossable CTOs that
entails use of a balloon placed over a wire that has been advanced though the subintimal space to “anchor”
the guidewire that has crossed through the CTO true lumen enabling lesion crossing with a balloon.
J INVASIVE CARDIOL 2013;25(10):552-554
Key words: chronic total occlusions, PCI, complications
__________________________________
Inability to cross the lesion with a guidewire is the most common reason for failure of chronic total occlusion
(CTO) percutaneous coronary intervention (PCI).1 Failure to cross the CTO after successful guidewire
crossing is the second most common cause for CTO PCI failure, occurring in up to 10% of cases.2,3 Several
techniques have been described to assist crossing of “balloon-uncrossable” CTOs, such as the use of the
Tornus catheter (Asahi Intecc), maneuvers to increase guide catheter support (such as use of guide catheter
extensions and various anchor techniques), use of various microcatheters (such as the Tornus or Corsair
[Asahi Intecc] and Finecross [Terumo]), and use of rotational atherectomy or laser.4 We report a novel
“subintimal distal anchor” technique that can enable crossing of balloon-uncrossable CTOs
when other maneuvers fail.

Technique Description
A 62-year-old man with a history of hypertension, severe peripheral arterial disease, and
systolic heart failure presented with limiting angina in spite of optimal medical therapy. Diagnostic angiography
revealed a mid-right coronary artery (RCA) CTO with non-obstructive disease in the left anterior descending
and circumflex arteries and the patient was referred for CTO PCI.
Bilateral femoral access was obtained with 8 Fr sheaths and anticoagulation was achieved with unfractionated
heparin. Bilateral injection confirmed mid-RCA occlusion with reconstitution via collaterals from the left
anterior descending and the circumflex arteries (Figures 1A and 1B). The RCA was engaged with an 8 Fr AL1
guide that fit well and provided good support.Antegrade crossing was successful with a Pilot
200 guidewire (Abbott Vascular) via a Valet microcatheter (Volcano Corporation) (Figure 1C).
We were unable to cross the lesion with a balloon in spite of using multiple 1.20 mm, 1.25
mm, and 1.5 mm balloons. Several balloons were inflated at high pressure and ruptured
within the proximal cap in an attempt to modify the lesion, without success. A Corsair and
Finecross microcatheter also failed to cross (Figure 2A) even after using an 8 Fr Guideliner
(Figure 2B) for additional support.
Several passes with a 0.9 mm coronary laser catheter (Spectranetics) operated at maximum energy and
fluency were unsuccessful (Figure 2C), as was use of an anchor balloon in the acute marginal branch (Figure
3A). A Tornus catheter was not available at the time of the procedure. Attempts to exchange the Pilot 200
guidewire for a Rotafloppy guidewire (BostonScientific) also failed.
The lesion was crossed subintimally with a second Pilot 200 guidewire that was knuckled to
the distal RCA (Figure 3B). Reentry attempts using the Stingray balloon wire (BridgePoint
Medical) failed (Figure 3C), likely due to diffuse disease of the distal vessel. We inflated a 3.0
mm balloon over the subintimal wire in the distal RCA that “anchored” the proximal guidewire
(Figure 4A) and enabled advancement of a 1.5 mm balloon through the CTO. The RCA CTO was successfully
predilated and stented with four everolimus-eluting stents with an excellent final angiographic result (Figure
4B). After the procedure, the patient’s angina resolved.

https://www.invasivecardiology.com/articles/subintimal-distal-anchor-technique-%22balloon-uncrossable%22-chronic-total-occlusions 1/3
4/3/2018 Subintimal Distal Anchor Technique for “Balloon-Uncrossable” Chronic Total Occlusions | Journal of Invasive Cardiology

Discussion
These cases illustrate a creative solution to balloon-uncrossable CTOs, ie, use of a
balloon placed over a wire that has been advanced though the subintimal space to anchor the
guidewire that has crossed through the CTO true lumen and enable lesion crossing with a
balloon.
Failure to cross a lesion with a balloon is most often due to severe calcification at the
occlusion site and can be challenging to overcome. Several strategies have been proposed,
and can be summarized into two categories: (1) strategies that increase guide-catheter support; and (2)
strategies that provide lesion modification.2,5-12
Strategies that increase guide-catheter support include deep-guide intubation (which can, however, be
challenging with the 8 Fr guides often used for transfemoral CTO PCI), use of guide-catheter extensions, such
as the Guideliner catheter (Vascular Solutions) and the Guidezilla (Boston Scientific), and use of various
anchor techniques (such as side-branch anchor and distal anchor).
Strategies that involve lesion modification include “rupturing” small balloons advanced as far as possible into
the lesion in an attempt to modify the proximal cap (a technique often called “grenadoplasty”), use of various
microcatheters, such as Tornus (specifically designed to “screw into” resistant lesions, creating a channel),
Corsair or Finecross, and use of laser or the Crosser catheter (Flowcardia, Inc) or rotational atherectomy.
However, rotational atherectomy requires wire exchange for a 0.009˝ dedicated guidewire, which may not
always be feasible through the CTO.
The balloon anchoring technique was initially described by Fujita in 2003 as inflation of a balloon in the side
branch of a target coronary vessel to facilitate equipment delivery to a target lesion.5 Distal anchoring is a
variation of this technique in which a balloon is inflated distal to or at the target lesion to enhance support for
equipment delivery.11 A modified version of the distal anchor technique was used to cross a balloon-
uncrossable CTO in our patient by performing distal balloon inflation within the subintimal space.
The subintimal distal anchor technique has limitations; it requires subintimal wire crossing, which may not
always be feasible, as the wire may track side branches. Subintimal crossing can cause subintimal hematoma
that may compress the distal true lumen; this is best prevented by limiting as much as possible the size of the
“knuckle” or by using the CrossBoss dedicated microdissection catheter (BridgePoint Medical/Boston
Scientific). It is important to ensure that the subintimal guidewire has not exited the adventitia, which is best
accomplished using dual injection. Inflating balloons in the subintimal space carries risk of vessel rupture that
can be minimized by using intravascular ultrasonography to determine the size of the balloon. For the same
reason, inflation pressures are usually <8-10 atm. Distal anchoring also requires at least a 7 Fr guide catheter,
which may limit its use in transradial CTO interventions unless sheathless guides are used.
In summary, the subintimal distal anchor technique can be a useful second-line strategy for crossing balloon-
uncrossable CTOs.
Acknowledgment. We gratefully acknowledge the tremendous support of the cardiac catheterization
laboratory team at the Dallas VA Medical Center for enabling the development of novel catheterization
techniques and the performance of clinical research.

References
1. Stone GW, Reifart NJ, Moussa I, et al. Percutaneous recanalization of chronically occluded coronary
arteries: a consensus document: part II. Circulation. 2005;112(16):2530-2537.
2. Pagnotta P, Briguori C, Mango R, et al. Rotational atherectomy in resistant chronic total
occlusions. Catheter Cardiovasc Interv.2010;76(3):366-371.
3. Stone GW, Colombo A, Teirstein PS, et al. Percutaneous recanalization of chronically occluded
coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc
Interv.2005;66(2):217-236.
4. Brilakis ES, Banerjee S. Crossing the “balloon uncrossable” chronic total occlusion: Tornus to the
rescue. Catheter Cardiovasc Interv.2011;78(3):363-365.
5. Fujita S, Tamai H, Kyo E, et al. New technique for superior guiding catheter support during
advancement of a balloon in coronary angioplasty: the anchor technique. Catheter Cardiovasc
Interv.2003;59(4):482-488.
6. Hirokami M, Saito S, Muto H. Anchoring technique to improve guiding catheter support in coronary
angioplasty of chronic total occlusions. Catheter Cardiovasc Interv. 2006;67(3):366-371.
7. Kirtane AJ, Stone GW. The Anchor-Tornus technique: a novel approach to “uncrossable” chronic total
occlusions. Catheter Cardiovasc Interv. 2007;70(4):554-557.
8. Brilakis ES, Banerjee S. Novel uses of the Proxis embolic protection catheter. Catheter Cardiovasc
Interv. 2009;74:438-445.

https://www.invasivecardiology.com/articles/subintimal-distal-anchor-technique-%22balloon-uncrossable%22-chronic-total-occlusions 2/3
4/3/2018 Subintimal Distal Anchor Technique for “Balloon-Uncrossable” Chronic Total Occlusions | Journal of Invasive Cardiology

9. Shen ZJ, Garcia-Garcia HM, Schultz C, van der Ent M, Serruys PW. Crossing of a calcified “balloon
uncrossable” coronary chronic total occlusion facilitated by a laser catheter: a case report and review
recent four years’ experience at the Thoraxcenter. Int J Cardiol.2010;145(2):251-254.
10. Fang HY, Lee CH, Fang CY, et al. Application of penetration device (Tornus) for percutaneous coronary
intervention in balloon uncrossable chronic total occlusion-procedure outcomes, complications, and
predictors of device success. Catheter Cardiovasc Interv. 2011;78(3):356-362.
11. Mahmood A, Banerjee S, Brilakis ES. Applications of the distal anchoring technique in coronary and
peripheral interventions. J Invasive Cardiol. 2011;23(7):291-294.
12. Hu XQ, Tang L, Zhou SH, Fang ZF, Shen XQ. A novel approach to facilitating balloon crossing chronic
total occlusions: the “wire-cutting” technique. J Interv Cardiol. 2012;25(3):297-303.

https://www.invasivecardiology.com/articles/subintimal-distal-anchor-technique-%22balloon-uncrossable%22-chronic-total-occlusions 3/3