86 • HJC (Hellenic Journal of Cardiology)

Hellenic J Cardiol 2011; 52: 86-90

Case ReportCase Report

Manuscript received:September 5, 2009;Accepted:March 5, 2010.

Address:Emmanouil S. Brilakis

Dallas VA Medical Center (111A)4500 South Lancaster Road Dallas, TX 75216, USAe-mail: esbrilakis@yahoo.com

Key words: Chronic total occlusion, new devices, subclavian artery occlusion, coronary-subclavian steal, angioplasty, stenting.

Use of the Frontrunner Catheter to Cross a Chronic Total Occlusion of the Left Subclavian ArteryTesfaldeT T. Michael, subhash banerjee, eMManouil s. brilakis

VA North Texas Healthcare System and University of Texas, Southwestern Medical Center, Dallas, Texas, USA

Crossing a subclavian artery chronic total occlusion may be challenging. We report the treatment of such an occlusion in a patient with a patent left internal mammary graft to the left anterior descending artery, who presented with progressive angina. Several attempts to cross the occlusion, both antegrade and retrograde, with various guidewires failed. The lesion was successfully crossed antegradely using the Frontrunner cath-eter and was successfully stented with resolution of the patient’s angina.

C hronic total occlusions (CTOs) of the subclavian artery (SA) are challenging to treat, mainly be-

cause they are difficult to cross.1,2 The Frontrunner blunt microdissection cath-eter has been successfully used to recan-alize CTOs of the lower extremity,3,4 but there is no report of its use in the SA. We present a case in which a proximal left SA CTO was successfully crossed using the Frontrunner catheter, after conventional crossing attempts failed.

Case presentation

A 50-year-old woman with diabetes, hy-pertension and dyslipidemia, who was a current smoker, presented with progres-sive angina pectoris for 6 weeks. Eighteen months prior to admission she had un-dergone coronary artery bypass grafting (CABG) with a left internal mammary ar-tery (LIMA) graft to the left anterior de-scending artery and a saphenous venous graft (SVG) to the first obtuse marginal branch. Following CABG she was angi-na-free until her recent admission, when she presented with progressively worsen-

ing chest pain, shortness of pain and dia-phoresis. The troponin and CK-MB levels were 0.03 ng/ml and 3.9 ng/ml, respective-ly. Electrocardiography showed ST-seg-ment depression in the inferolateral leads.

Coronary angiography showed 2-ves-sel coronary artery disease involving the first obtuse marginal branch and the mid right coronary artery (Figures 1A, 1C). The SVG to the first obtuse marginal branch was occluded. The LIMA to the mid left anterior descending artery graft filled retrogradely (Figures 1C, 1D, 1F). Aortic arch angiography demonstrated a totally occluded left subclavian artery at its origin (Figure 1E). The first obtuse marginal branch was predilated with a 2 × 10 mm Sprinter balloon (Medtronic Vas-cular, Inc., Santa Rosa CA, USA) and was successfully stented with a 2.5 × 14 mm Endeavor drug-eluting stent (Medtron-ic Vascular) (Figure 1D). The mid right coronary artery was predilated with a 2 × 10 mm Sprinter balloon (Medtronic Vas-cular) at 10 atmospheres and stented with a 2.5 × 14 mm Endeavor stent (Medtronic Vascular) (Figure 1B).

The patient continued to have ex-

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Frontrunner for Subclavian CTO

A

C

B

D

FE

Figure 1. Right coronary angiography in the right anterior oblique projection showing a mid vessel stenosis (arrow, panel A), that resolved after stenting (arrow, panel B). Left coronary angiography in the right anterior oblique caudal projection showing a significant first obtuse marginal lesion (arrow, panel C) that resolved after stenting (arrow, panel D). Aortic arch angiography in the left anterior oblique projec-tion showing a chronic total occlusion of the proximal left subclavian artery (arrow, panel E). Left coronary angiography demonstrating an ostial left main lesion (arrowhead), a severe lesion in the first obtuse marginal branch (single arrow, panel F), and retrograde filling of the left internal mammary graft (multiple arrows, panel F).

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C D

A B

Figure 2. Bilateral injection via a brachial artery catheter and a femoral artery sheath demonstrating complete occlusion of the proximal left subclavian artery and extraluminal position of the Frontrunner catheter (arrow, panel A). Subclavian angiography via a left brachial artery catheter showing intraluminal location of the tip of the Frontrunner catheter (arrow, panel B) that was advanced antegradely via the left femoral artery sheath. Balloon predilatation of the proximal left subclavian artery was per-formed (arrow, panel C). Left subclavian artery angiography after stenting (arrow, panel D) showing no residual left subclavian artery stenosis.

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ertional angina and was subsequently referred for angioplasty of the left subclavian CTO. Angioplas-ty was attempted antegradely using a 90 cm long 7 French sheath (Cordis, Warren NJ, USA) and several guidewires, including a 0.035 inch Glidewire (Teru-mo, Sommerset NJ, USA), 0.014 Miracle Bro 3, 6, and 9 wires, (Asahi, Abbott Vascular, Santa Clara CA, USA), the Cross it 100 (Abbott Vascular) and the Regatta HS Guidewire (Cordis). However all at-tempts to cross failed.

The patient returned 3 weeks later for another attempt at angioplasty of the left subclavian artery CTO. Arterial access was obtained via the right femo-ral and the left brachial artery. Subclavian angiogra-phy, through a catheter inserted via the brachial ar-tery, revealed reconstitution of the subclavian artery proximal to the vertebral artery with no distal disease. Multiple attempts to cross the occlusion retrograde-ly with a Glidewire (Terumo) inserted via a Tem-po Aqua catheter (Cordis), with a Runthrough wire (Terumo) inserted via a Venture catheter (St. Jude Medical, Minnetonka MN, USA), and with a Front-runner catheter (Cordis) failed (Figure 2A).

The Frontrunner catheter was subsequently in-troduced over a 7 French 90 cm Pinnacle destination sheath (Terumo) that engaged the left subclavian ar-tery stump and successfully crossed the CTO. The in-traluminal location of the Frontrunner catheter tip was confirmed with contrast injection through a left brachial artery multipurpose catheter (Figure 2B). The Frontrunner catheter delivery sheath was ad-vanced over the catheter and a Glidewire (Terumo) was inserted antegradely into the left subclavian ar-tery. The subclavian artery was sequentially predilat-ed with 4 × 40 mm and 4 x 60 mm Powerflex balloons (Cordis) (Figure 2C). An 8 × 27 mm Express stent (Boston Scientific Natik MA, USA) was deployed, with an excellent final angiographic result (Figure

2D). Following the procedure the patient reported complete angina resolution.

Discussion

Our case illustrates the use of the Frontrunner cathe-ter to successfully cross an ostial left subclavian CTO, in a patient with coronary-subclavian steal.

Coronary-subclavian steal is increasingly recog-nized as a cause of angina after CABG, which is why it is currently recommended to perform subclavian angiography in all prior CABG patients in whom the LIMA or right internal mammary artery have been used as bypass conduits.5 The time of presentation of coronary-subclavian steal varies. The average inter-val from CABG to coronary-subclavian steal symp-toms was 6.9 years in a study by Elian et al, with more than half the patients presenting 9 or more years af-ter CABG.6 Westerband et al reported that coronary steal occurred between 2 and 31 (mean 14) years after CABG.7

Percutaneous angioplasty and stenting is increas-ingly being considered as the therapy of choice for subtotal SA stenosis, because it carries a lower risk of complications compared to surgery.8,9 The success rate for endovascular therapy of totally occluded SA lesions is low (46-83%, Table 1).1,2,10-14 Schillinger et al2 reported that complete occlusion and long lesions (> 2cm) were correlated with a lower success rate, and that success rates were higher via the brachial ap-proach (in 10 of 14 patients, 71%) compared to the transfemoral route (in 3 of 13 patients, 23%, p=0.02). Obtaining both antegrade and retrograde access may facilitate intervention in total SA occlusions,1 as in our patient.

The Frontrunner catheter uses controlled blunt microdissection to separate atherosclerotic plague and create a channel through a CTO, thereby en-

Table 1. Success rates of subclavian artery endovascular treatment.

Author Year Overall Subtotal occlusions Complete occlusions

Henry1 2007 94% (223/237) 100% (192/192) 69% (31/45)Schillinger2 2001 85% (98/115) 100% (98/98) 76% (13/17)Przewlocki10 2004 91.7% (44/48) 100% (39/39) 56% (5/9)Amor11 2004 93.3% (83/89) 100% (76/76) 54% (7/13)Motarjeme12 1996 91% (73/80) 100% (67/67) 46% (6/13)Mathias13 1993 83% (38/46) * 83% (38/46)Hebrang14 1991 86.6% (45/52) 93% (40/43) 56% (5/90)

* Mathias el al reported only reported outcomes in complete subclavian occlusions.

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abling wire placement and subsequent angioplasty and stenting. Blunt dissection takes advantage of the differential elastance between intraluminal plaque and adventitia to preferentially disrupt the athero-sclerotic plaque while maintaining the integrity of the outer arterial wall layer. The Frontrunner catheter has been successfully used for treating lower extrem-ity arterial CTOs.3,4 Our case shows that it can also facilitate crossing of subclavian CTOs. Special care should be taken to confirm the endoluminal position of the Frontrunner by contralateral injections after crossing, so as to minimize the risk of perforation.

In summary, coronary-subclavian steal should be included in the differential diagnosis of angina after CABG. Use of the Frontrunner blunt microdissection catheter may allow crossing of chronic total subclavi-an artery occlusions once conventional crossing tech-niques have failed.

References

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2. Schillinger M, Hauner M, Schillinger S, Ahmadi R, Minar E. Risk of stratification for subclavian artery angioplasty: is there an increased rate of restenosis after stent implantation? J Endovasc Ther. 2001; 8: 550-557.

3. Mossop P, Cincotta M, Whitbourn R. First case reports of controlled blunt microdissection for percutaneous translumi-nal angioplasty of chronic total occlusions in peripheral arter-

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