Us efulness o of the Cor rsair Micro ocatheter for Treatm ment of Co

Usefulness o
of the Corrsair Micro
ocatheter for Treatm
ment of Co
omplex Ch
hronic Tottal Occlus
sion
Yoritak
ka Otsuka, MD, Keita Nakamurra, MD, Taro Sa
aito, MD
ABSTRACT: Percuttaneous corona
ary intervention (PCI)
(
for the tre
eatment of chron
nic total occlusio
on (CTO) is onee of the most tec
chnically challen
nging
areas
s of intervention
nal cardiology. When
W
CTO is co
ombined with an
ngulation and to
ortuosity of the coronary
c
artery, the technical complexity of PC
CI for
CTO is magnified. In
n this report, we describe a case
e of successful revascularizatio
on of a CTO lesion in the compllex circumflex anatomy using a novel
micro
ocatheter (the C
Corsair catheter)) along with an antegrade
a
apprroach to facilitate guidewire pas
ssage through a proximal steep
p angulation and
d to
cross
s the circumflexx CTO lesion tha
at was unrespon
nsive with conve
entional microca
atheters.
J INVASIVE C
CARDIOL 2012;;24(2):E35-E38
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Percutaneous coron
nary intervention
n (PCI) for chron
nic total occlusio
on (CTO) of corronary arteries is one of the moost technically challenging area
as for
the in
nterventional ca
ardiologist with lo
ower procedura
al success rates and higher com
mplication rates compared with those for the no
on-occluded corronary
arteries or acutely-occluded arteriess. In addition, clinical and angio
ographic resteno
osis or re-occlusion occurs withh greater freque
ency after PCI of
o
1
CTOs compared with non-occluded
d lesion. Howev
ver, it has been reported that su
uccessful revascularization of a CTO leads to a significantly
impro
oved survival ra
ate and a reducttion in major carrdiac adverse evvent in patients in the long term
m.
2-4
Drug-eluting stents ((DES) have bee
en demonstrated
d to markedly re
educe in-stent restenosis for on
n-label and off-laabel lesions
lesions.
7,8
5,6
in
ncluding CTO
Long-term
m patency and frreedom from res
stenosis after su
uccessful recan
nalization of CTO
Os with DES greeatly reduce the
e rate of mortalitty and
cardiac events. Furth
hermore, severa
al procedural te
echniques such as retrograde approach
a
and va
arious devices fo
for CTO lesions have been rece
ently
deve
eloped and subssequently succe
ess rates of CTO
O recanalization
n have increased
d.
9-14
The complexity
c
of PC
CI for CTO is magnified
m
when CTO
C
lesion is co
ombined with angulation and to
ortuosity of the ccoronary artery. Proximal steep
p
angu
ulation quite likely contributes to
o the reduced su
uccess rate of in
nterventions on chronically occ
cluded circumfleex arteries observed in some
serie
es.
15,16
In this report, we desscribe a case off successful com
mplex circumfle
ex PCI using a novel
n
microcathe
eter (the Corsai r catheter) ante
egradelly to facilitate
guide
e wire advancem
ment through a proximal angula
ated circumflex CTO lesion tha
at was unrespon
nsive with conveentional microca
atheters.
Case
e Report. A 40-yyear-old male patient
p
with multtiple coronary ris
isk factors of hyp
ypertension, hyp
perlipidemia, diaabetes mellitus and
a hyperuricem
mia
was admitted
a
to our hospital becausse of angina pectoris. He had e
established end
d-stage renal dis
sease and had aalready been on
n hemodialysis before
b
admiission. Coronaryy angiography showed
s
a CTO of
o the proximal lleft circumflex (L
LCx) artery com
mbined with steep
ep angulation (F
Figures 1a and b).
b PCI
was performed
p
using
g an antegrade approach. A 6 Fr
F BL 4.0 Heartr
trail guiding cath
heter (Terumo) or
o a 7 Fr BLH B
Brite tip guiding catheter
c
(Cordiss) was
used
d via the right fem
moral artery. We
W tried to proceed the Finecrosss microcatheterr, (Terumo) to th
he completely ooccluded LCx arrtery using a Rin
nato
guide
ewire (Asahi Inte
ecc), but multiple attempts to deliver
d
the micro
o-catheter to the
e LCx
occlu
usion were unsu
uccessful due to
o the prolapse of
o microcatheterr into the patent left
anterrior descending (LAD) artery (F
Figures 1c and d).
d The extreme
ely steep angle of
o LCx
artery
ry in its take-off ffrom the very la
arge left main tru
unk seemed to tthe cause of the
e
difficulty to advance the microcathe
eter. To take mo
ore co-axial direcction to the LCx
x artery,
the guiding
g
catheterr was changed to
t a 6 Fr Amplattz 3.0 Heartrail g
guiding catheterr. Then,
an X-treme
Xguidewirre (Asahi Intecc)
c) was used to select the atrial b
branch for a Fin
necross
micro
o-catheter delive
ery (Figure 1e) and the Finecro
oss micro-cathe
eter could succe
essfully
cross
s the steep anglle of LCx arteryy (Figure 1f). Sub
bsequently, an X
X-treme guidew
wire and
the Finecross
F
micro--catheter were further
f
advance
ed toward the prroximal part of th
he CTO
lesion
n. A Wizard 3 (JJapan Lifeline), a Miracle 6, and a Conquest P
Pro guidewire (A
Asahi
Intec
cc) were used to
o cross this CTO
O lesion but werre unsuccessfull because of insufficient
back
kup guidewire su
upport (Figures 2a and b). Therrefore, we chan
nged the micro-c
catheter
to a Corsair
C
micro-ca
atheter. A Corsa
air micro-cathetter was easily ad
dvanced toward
d the just proxim
mal part of the C
CTO lesion using
g a similar meth
hod.
Finallly, the Conquesst Pro guidewire
e (Asahi Intecc) was able to cro
oss this CTO les
sion (Figure 2c). Although a Coorsair micro-cath
heter was not ab
ble to
cross
s this CTO lesio
on, a 1.25-mm x 10-mm Tazuna
a balloon (Terum
mo) was able to
o cross and succ
cessfully dilatedd the CTO lesion
n. A 2.5-mm x 15-mm
Signe
et Pro balloon (S
(St. Jude Medica
al) was then use
ed to open this C
CTO lesion furth
her. Stent impla
antation was succcessfully perforrmed using a 3.5-mm
x 23--mm Xience V sstent (Abbott). Final
F
coronary an
ngiogram showe
wed a satisfactorry result without any complicatioons (Figures 2d
d and 2e).
Discussion. Microcatheter techniqu
ue provides sup
pport to
adva
ance the guidew
wire and is usefu
ul in the PCI of complex
c
anato
omy. However, this technique is occasionally insufficient for
the trreatment of CTO
O combined with angulation, to
ortuousity and
severe calcification o
of the coronary artery. In the tre
eatment of the
lesion in the LCx artery with a steep
p angle in its tak
ke-off from left
main trunk, a prolapse of the distal wire and the support catheter
such as the over-the
e-wire balloon or microcatheter frequently
occurs and the proce
edure fails. If a sufficient length
h of wire could n
not be placed diistally from the proximal
p
angulaation, an advanc
cement of the
micro
ocatheter would
d be impossible and could not give
g
enough sup
pport to cross a CTO lesion with
h wire, and vicee versa. Recentlly, it has been
17
18
reporrted that the utility of the deflecctable tip Venturre Catheter or Twin-Pass cath
heter, or doublle catheter techhnique using a 5 Fr VERT cathe
eter
19
facilittated guidewire crossing during
g PCI for comple
ex proximal circcumflex lesions. However, these devices are uuncommonly ava
ailable for daily
practtice.
20
The Corsair
C
microca
atheter (Asahi In
ntecc) was origin
nally developed as a collateral channel
c
dilator to
t facilitate retroograde approaches for PCI of CTO.
C
This is an over-the-w
wire hybrid catheter that has features of a micrrocatheter and a support catheter. The shaft coonsists of 8 thin
n wires wound with
w 2
large
er wires.20 On th
he other hand, the
t shaft of the Tornus microca
atheter (Asahi In
ntecc), which wa
as useful for callcified lesion, co
onsists of 8 larger
wires
s wound.
21,22
The spiral structurre of Corsair mic
crocatheter allo
ows the bidirectio
onal rotation giv
ves crossing cappability in small tortuous collate
eral
channels (Figure 3). The braided po
ortion of the catheter is covered
d with polyamide elastomer, an
nd the inner lum
men of the shaft is lined with a
fluoro
opolymer layer tthat enables tip injections and facilitates
f
the gu
uidewire movem
ment. The table demonstrates tthe details of the
e 4 microcathete
ers:
2.1 Fr
F Tornus, 2.6 Fr Tornus, Corsa
air and Finecros
ss microcatheterrs. The characte
eristic features of
o the Corsair m
microcatheter arre as follows: the
e
smallest outer and in
nner diameter fo
or the distal tip, the smallest inn
ner diameter an
nd the larger outter diameter for the distal part, the smallest inn
ner
diameter and the larrger outer diame
eter for the prox
ximal part, which
h gives better crrossability of the
e distal tip and bbetter backup guidewire support
comp
pared with convventional micro-ccatheter.
It has
s been reported
d that PCI for CT
TO lesions with the Corsair miccro-catheter in th
he retrograde approach had a hhigh success ra
ate and this wass
20
attrib
buted to the enhanced crossabiility in the collate
eral channel an d better backup
p guidewire supp
port. Althoughh this catheter was
w developed fo
or
20
retrog
grade approach
h PCI of CTO, these characteristics are also useful for anteg
grade approach PCI of the CTO
O lesion whenev
ver angulation and
a
tortuo
ousity of the corronary artery is encountered as
s in the case we
e describe here that was initially
y unresponsive with a conventiional micro-cath
heter
(Figu
ure 3). Therefore
e, the Corsair micro-catheter
m
co
ould be the first choice for the CTO-PCI
C
with se
evere or compleex lesion morpho
ology, not only after
a
a
failed
d attempt of the retrograde app
proach, but also when making a
an initial attemptt using an anteg
grade approachh.
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Olivari Z, Rubartelli P, Piscione F, et al. Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions:
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Alhaddad IA. Novel double catheter technique in complex percutaneous coronary interventions. Catheter Cardiovasc Interv. 2006;67:912-914.
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From the Department of Cardiology, Fukuoka Wajiro Hospital, Fukuoka, Japan.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. No authors reported conflicts regarding the content
herein.
Manuscript submitted August 19, 2011, provisional acceptance given September 15, 2011, final version accepted September 27, 2011.
Address for correspondence: Yoritaka Otsuka, MD, FACC, FESC, Department of Cardiology, Fukuoka Wajiro Hospital, 2-2-75, Wajirogaoka, Higashi-ku, Fukuoka
811-0213, Japan. E-mail: yotsuka@f-wajirohp.jp
206
Usefulness of Corair Microcatheter for Treatment of
Complex Chronic Total Occlusion
複雑な CTO 症例の治療における Corsair microcatheter の実用性
Yoritaka Otsuka, MD, Keita Nakamura, MD, Taro Saito, MD
J INVASIVE CARDIOL 2012;24(2):E35-E38
CTO 治療の PCI はインターベンショナルカーディオロジーにおいて最も技術的にチャレンジングな領域であると言える。更
に CTO が冠動脈の曲りや蛇行を伴う場合には、CTO-PCI の複雑さは拡大する。我々は複雑な形態をした回旋枝の CTO
病変に対し、従来のマイクロカテーテルでは効果が無かったのに対し新しいマイクロカテーテル（Corsair カテーテル）を使
いアンテグレードから病変部手前の急峻な屈曲部を越え、更に回旋枝の CTO 病変部までワイヤーを通過させることに成功
し、血行再建にし得たケースを紹介する。
---------------------------------------------------------------------------------------------症例報告：
40 歳男性、高血圧、高脂血症、糖尿病、高尿酸血症あり。
CAG にて急峻な屈曲を伴う LCｘ近位部に CTO を確認した（Figure1:a,b）。アンテグレードアプローチにて PCI を開始した。
右大腿骨動脈アプローチにて 6F BL4.0 Heartrail または 7F BLH Britetip を使用した。Rinato を使い Finecross の病変部
までのアプローチを試みるが、何度トライしても LAD 方向に Finecross が向かおうとする為、デリバリーすることができなか
った（Fig1: c,d）。非常に強い屈曲を伴う LCx がかなり大きな LMT から派生していることが、マイクロカテーテルの通過を阻
害している原因と思われ、LCx に対してコアキシャルにガイディングカテーテルを向ける為、6F Amplatz 3.0Heartrail に変
更した。また、X-treme で心房枝（atrial）を選択したことで（Fig1;e）、Finecross は LCx の急峻な角度を通過することに成功
（Fig.1:f）。その後、X-treme と Finecross を CTO 近位部まで進めた。Wizard3、Miracle6、Conquest Pro を使って CTO ク
ロスを試みたがワイヤーのサポートが弱く通過しなかった（Fig.2a,b）。そこでマイクロカテーテルを Corsair に交換すると、
Corsair は CTO 手前まで容易に進み、Conquest Pro で CTO のクロスに成功した（Fig.2c）。Corsair 自身は病変を通過し
なかったが、1.25x10mm Tazuna が通過し病変部の拡張に成功した。最終的には 2.5x15mm Signet Pro で拡張した後に
Xience V を留置し良好な結果を得た。
ディスカッション：
マイクロカテーテルを使うことによってガイドワイヤーがサポートされ、複雑なアナトミーの PCI には有効だが、屈曲や血管
の蛇行、高度石灰化を伴う CTO 病変の場合にはしばしば不十分であることが多い。LMT から派生する起始部に急峻な角
度を伴う LCx の病変を治療する際には、ワイヤー先端や OTW バルーン・マイクロカテーテルなどのサポートカテーテルが
プロラプスし、手技の不成功に繋がりやすい。手前の屈曲部から十分にワイヤーを進められないとマイクロカテーテルを追
従させることは不可能で、CTO をワイヤークロスさせる十分なサポートが得られない。
近年では、複雑な LCx 近位部の病変に対して、Venture カテーテルや Twin-Pass カテーテル、5Fr.VERT カテーテルを用
いた W カテーテルテクニックを使ったワイヤー通過成功例が報告されているが、こうしたデバイスを日常的に使うことは困
難である。
Corsair は CTO-PCI においてレトログレードアプローチを容易にする為の collateral channel dilator として開発された製品
であり、マイクロカーテルとサポートカテーテルの両面の機能を有している。
Corsair をレトログレードアプローチに使用した CTO-PCI において高い成功率を得たということが報告されており、それはコ
ラテラルチャンネルの高い通過性とガイドワイヤーの良好なバックアップサポートに起因している。Corsair はレトログレード
アプローチ用として開発されたデバイスであるが、こうした特性は我々が今回経験したように、通常のマイクロカテーテルで
は上手くいかないような、角度や蛇行を伴った CTO 病変に対するアンテグレードアプローチにも有用である。
よって、Corsair はレトログレードアプローチで成功しなかった後に使用するというだけではなく、アンテグレードアプローチで
最初からトライする場合でも、高度もしくは複雑な病変形態の CTO に対しては第一選択となり得る。

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