Epicardial Channel: Friend or Foe
Dr. Ivan WONG
Queen Elizabeth Hospital, Hong Kong
A 77-year-old lady with history of ischemic heart disease with known LCX CTO. We used bilateral radial approach with 7Fr EBU 3.5 guiding catheter for left main coronary (LMN) via right radial and 7Fr IL 3.5 guiding catheter for right coronary artery (RCA) via left distal radial (Movie 1, Movie 2). There is common epicardial channel to ostial marginal branch (OM) which was supplied from both posterior descending artery (PDA) and left anterior descending artery (LA) (Figure 1).
After failing antegrade wiring (Movie 3), we attempted retrograde wiring via PDA channel with Suoh 03 guidewire with Caravel microcatheter support. However, significant whipping of guidewire was noted making further wiring impossible. Therefore, we switched to retrograde attempt via LAD epicardial channel with SionBlack guidewire. A small concealed perforation at epicardial channel was noted (Movie 4) and the patient’s hemodynamics was stable. Thus, further retrograde wiring was continued and successfully crossed the CTO lesion with direct wiring into ipsilateral guiding catheter (Movie 5). However, either antegrade or retrograde microcatheters failed to cross the CTO lesion because of inadequate support (Figure 2). We therefore used IL 3.5 guiding catheter from right coronary as ping pong guide and placed it at ostium LMN for retrograde Sionblack GW anchoring. Retrograde microcatheter finally crossed the CTO lesion (Movie 6, Movie 7).
The patient then developed hypotension. Bedside Echocardiogram showed significant pericardial effusion. Urgent pericardiocentesis was done and fluid resuscitation was commenced. We engaged ostium RCA with 7Fr JR4 guiding catheter via right femoral artery. Angiogram showed active extravasation at PDA epicardial channel (Movie 8). Multiple coils were deployed via Progreat microcatheter and the leakage was sealed off (Movie 9, Figure 3). We continued the procedure and used RG3 for externalisation via IL 3.5. We switched back to antegrade wiring after antegrade microcatheter crossing. We then removed retrograde system back to LAD. However, patient developed hypotension again with increased pericardial drainage output. Angiogram confirmed active extravasation at epicardial channel again (Movie 10). Coil embolization was performed with coils deployed at channel feeders via OM and LAD branch. Complete seal off of perforation was achieved (Movie 11). The case was finally completed with stenting of the CTO lesion (Movie 12).
Comments
The case demonstrates the challenges in retrograde CTO crossing using ipsilateral epicardial collaterals and complicated with perforation. The strategies of use of Ping-Pong guiding technique and GW anchoring for retrograde microcatheter lesion crossing were demonstrated. Finally treatment strategies for perforation of channel with multiple feeders by multiple coiling was necessary. Immediate action with pericardiocentesis was essential.