Dual guidewire balloon antegrade fenestration and re‐entry technique for coronary chronic total occlusions percutaneous coronary interventions

Abstract

Objectives: To describe the experience of coronary chronic total occlusions (CTOs) percutaneous coronary interventions (PCI) using antegrade fenestration and re-entry (AFR) technique with a dedicated dual guidewire balloon (DGB).Background: Antegrade dissection and re-entry (ADR) techniques has been emphasized in recent worldwide CTO consensus documents. We investigated the feasibility and safety of DGB as a dedicated device to perform guidewire-based AFR.Methods and Results: Fourteen consecutive patients with complex CTO (J-CTO score: 3.1 ± 0.9) underwent DGB-AFR in the years 2020-2021. DGB-AFR consists in advancing the DGB over a guidewire that reached the vessel distal to the CTO in an extra plaque fashion, inflating/deflating the DGB to create fenestration between subintimal space and the true lumen and advancing a proximal re-entry guidewire through fenestration in the true lumen. DGB-AFR alone was successful in 10 of 14 (71%) cases, a rescue wire-based ADR was needed in two cases for re-entry into the true lumen with a total success rate in 12 of 14 (86%) cases. Among all DGB-AFR cases, four (28%) were performed as a first-line strategy while the remaining 10 (71%) cases were performed as a bail-out strategy after failure of other antegrade crossings for 30 min of procedural time. No DGB-related complications were observed.Conclusions: DGB-AFR is a user-friendly reliable strategy for the treatment of many CTO lesions. It can be used as bail-out after failure of conventional antegrade wiring techniques, achieving high procedural success rate and low occurrence of procedural adverse events.

STAR procedure becomes SAFER: First‐in‐man case series of a new antegrade dissection re‐entry technique

“…14 Recently a dedicated AFR device has been tested and shown a similar procedural success rate (71%) to Stingray but only a marginal improvement in the procedural success rate compared with the original AFR technique (66% vs. 71%), possibly highlighting the intrinsic limitations of AFR itself (due to the presumptive transient nature of the fenestrations and the proximal position of the crossing wire relative to the balloon responsible for the fenestrations). 15…”

Dual guidewire balloon for antegrade fenestration re‐entry: A welcome addition to the CTO operators' armamentarium

“…In this issue of the Journal, Galassi et al 4 describe their initial experience with use of a dedicated device, the dual guidewire balloon (DGB) to perform AFR in CTO PCI. DGB‐AFR was attempted in 14 patients with complex CTO lesions, either as first‐line or as bail‐out after the failure of antegrade wiring or ADR, achieving technical success in 10 (71%) patients.…”

“…In a multicenter study of 41 patients, AFR was successful in achieving CTO recanalization in 27 (69.5%) patients. 3 In this issue of the Journal, Galassi et al 4 describe their initial experience with use of a dedicated device, the dual guidewire balloon AFR has strengths and limitations. Similar to all ADR strategies, use of AFR is not ideal in lesions with ambiguous proximal cap (unless when used as part of the "move the cap" techniques) and poor distal vessel quality.…”

Trends and evolution of antegrade dissection and re‐entry technique: A glimpse into the future of complex chronic total occlusions interventions

“…These issues might explain at least in part why the ADR technical success in the PROGRESS is lower than wire-based technical success in the ERCTO. Finally, despite wire-based ADR is emerging over device-based ADR, along with other refined techniques such as antegrade fenestration and re-entry, 7,8 it would be desirable a hybrid CTO operator has knowledge of both ADR techniques.…”