Percutaneous In Situ Coronary Venous Arterialization

Abstract

Abstract-Diffuse coronary artery disease is frequently untreatable by coronary artery bypass or angioplasty. Many such "no-option" patients have been subjects for trials of angiogenesis using growth factor manipulation or laser injury. We think these novel revascularization strategies are limited by insufficient inflow to putative areas of new microvasculature and thus seek a more mechanical solution. We report the use of a catheter-based system for arterializing the adjacent anterior cardiac vein in a patient with chronic total occlusion of the left anterior descending coronary artery. A composite catheter system (phased-array ultrasound imaging system mounted on a catheter with extendable nitinol needle) was used to deliver an exchange-length intracoronary guidewire from the proximal left anterior descending coronary artery into the parallel anterior interventricular vein. Using standard angioplasty techniques, a fistula was then constructed from the proximal artery to the coronary vein using a self-expanding connector. The proximal vein was blocked with a novel self-expanding "blocker," thus precluding "steal" through the coronary sinus and forcing retroperfusion of the anterior wall. The procedure was completed without complication, and a follow-up angiogram at 3 months confirmed continued patency of the arteriovenous connection. This patient, who had severe angina before the procedure, has been asymptomatic for 12 months. Percutaneous in situ venous arterialization may be an effective therapy for diffuse, "untreatable" coronary disease by supplying a robust inflow of arterialized blood via retroperfusion to severely ischemic myocardium. W ith the combination of coronary artery bypass surgery and percutaneous coronary interventions, many patients with symptomatic coronary insufficiency can be effectively revascularized. Each year in the United States alone, nearly 1 million individuals undergo a percutaneous catheterbased intervention, with intracoronary stents used in most. An additional half million Americans have their coronary disease treated by aortocoronary surgical bypass.Despite the successful and widespread application of these revascularization procedures, a large number of patients are not good candidates for either angioplasty or surgery. These "no-option" patients frequently have diffuse coronary disease without a discrete target for angioplasty, stenting, or surgical bypass. It has been estimated that Ͼ100 000 patients each year may fall beneath the no-option rubric. 1 Many of these patients have recently been investigational subjects in trials focused on angiogenesis by vascular growth factor infusions or laser injury.We suspect that gene therapy and laser revascularization strategies may have a fundamental flaw: the creation of new blood vessels in ischemic myocardial tissue requires significant arterial inflow, which is not obviously enhanced by these techniques. Therefore, we sought a novel percutaneous revascularization approach with the potential to provide robust arterial inflow to a sev...

Great cardiac vein variations

“…For example, Gerber et al (2001) suggest that patients with an AIA cross by GCV may not be candidates for percutaneous in situ coronary artery bypass (PICAB) because the overlap of vessels may obscure the detection of significant calcification. Oesterle et al (2001) indicate that their percutaneous in situ coronary venous arterialization (PICVA) procedure was carried out on a "parallel anterior interventricular vein" (implying a long left-side initial course). It is clear that the particular vein anatomy in individual patients influences the mechanics and outcomes of some procedures.…”

Anchorage of oligonucleotide hybridization by tethered phenazine nucleoside analogue

“…A phase 1 feasibility trial of PICVA was initiated in Germany in 1998. A description of this limited trial and a report of the first patient to have a successful PICVA is published [1]. This limited feasibility trial was designed to test the concept of PICVA and the practicality of the enabling devices for both PICVA and PICAB.…”

“…We introduced the concept of percutaneous in situ coronary artery bypass (PICAB) several years ago and suggested that it could ultimately replace bypass surgery as a less invasive approach to coronary revascularization (Fig. 1) [1]. Although this developing technology has been challenged by expected and unforeseen clinical and mechanical obstacles, we continue to believe that catheter‐based coronary bypass can become a broad‐based interventional application.…”

Efficacy of Sirolimus Eluting Stents Implantation in Diffuse (Long and Extremely Long) Coronary Atherosclerotic Lesions

“…предложена операция лазерной туннелизации мио-карда, однако, несмотря на вполне обнадеживающие первые клинические результаты [12][13][14], эта операция так и не смогла стать массовой при указанном типе атеросклеротических поражений коронарных арте-рий [15,16]. Другие методы, такие как in-situ артери-ализация венозной системы сердца из-за плохого состояния дистального русла [17], сочетание хирурги-ческой реваскуляризации с генной терапией (интра-коронарное введение фактора роста эндотелиальных клеток VEGF) [18] пока находятся на стадии разра-ботки. Интервенционные методы лечения до послед-него времени считались малоэффективными.…”