Intracoronary snaring of the retrograde guidewire: How to overcome extreme takeoff angles in chronic total occlusion percutaneous coronary intervention

Abstract

Extreme angulation of coronary artery takeoff represents a challenge for wiring and device advancement in percutaneous coronary intervention (PCI). This anatomic feature is particularly adverse in cases of chronic total occlusion (CTO) of the ostial-proximal segment of the target vessel. In this setting, the retrograde approach can help getting access to the occlusion. However, difficulties might arise at the critical step of wire externalization, due to the need to overcome the extreme ostial angle. Here, we describe a case of successful CTO PCI of the proximal circumflex artery, which presented an extreme angle at its takeoff. Due to inability to perform antegrade wiring of the occlusion, the retrograde approach was undertaken via epicardial collaterals from the right coronary artery. Since conventional attempts at re-entering the antegrade guiding catheter failed due to the aforementioned extreme angle, the retrograde wire was snared in the mid left anterior descending artery, and externalization was performed. This case demonstrates the usefulness of coronary snares in the CTO operator's toolkit and shows how such devices can be used to safely and successfully complete challenging retrograde procedures.

Intracoronary snaring of the retrograde guidewire: A novel method to solve compartment mismatch in complex retrograde CTO PCI

“…Intracoronary snaring has also been described, for example, to retrieve embolized material 10 or to overcome extreme angles where antegrade techniques fail. 11 However, ours is the first description of intracoronary snaring to create the connection between the antegrade and retrograde system during CTO PCI.…”

“…However, introduction of guide catheter extension‐facilitated reverse CART has greatly reduced the need to resort to this approach. Intracoronary snaring has also been described, for example, to retrieve embolized material 10 or to overcome extreme angles where antegrade techniques fail 11 …”

Current approaches for treatment of coronary chronic occlusions

“…Entrapping the retrograde wire inside the antegrade guiding catheter (or the mother-andchild guide catheter extension) could highly enhance the support for the final advancement of the retrograde microcatheter. The guidewire can be then exchanged with an externalization wire and the PCI can be finalized [79]. In case of unfavorable anatomy alternative techniques should be considered.…”