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We describe two cases of a retrograde approach to treat a chronic total occlusion (CTO) of the right coronary artery in which we were initially unable to achieve wire crossing. A novel technique of pushing both antegrade and retrograde balloons into the CTO lesion so that the balloons overlapped each other during inflation created a new confluent subintimal space allowing easy, reliable and rapid passing of the retrograde wire into the antegrade true lumen. This novel "confluent balloon" method is recommended to other operators who may struggle with wire crossing during a retrograde approach to CTOs.

Left main dissection is usually caused by catheter manipulation during diagnostic angiography and occasionally during angioplasty. It is a dangerous complication due to the potential risk of left main territory ischemia. We report a novel iatrogenic cause of left main dissection from a retrograde wire during ostial left anterior descending artery chronic total occlusion retrograde angioplasty. We also report the use of the antegrade balloon as a transit chamber for the retrograde wire after a successful reverse CART technique in order to prevent further left main dissection. This technique is applicable to other retrograde approaches for chronic total occlusion cases where proximal artery dissection is undesirable.

Retrograde approach via collateral channels in coronary angioplasty for chronic total occlusion (CTO) can improve the success rate. Most interventionists will meet a few cases where the retrograde approach will provide unequaled advantages, but many are held back from taking retrograde approach by lack of proper equipment and expertise. In this article, we give detail description of techniques to shorten the guiding catheter, to traverse the collateral channels, and to cross the CTO. We also illustrate the difficulties in collateral channel crossing with different examples providing a basic guide for case selection purposes. We hope that many others would find rewardingly successful cases of retrograde approach CTO percutaneous coronary intervention, as in our experience., ((c) 2008 Wiley-Liss, Inc.)

We report on three cases of left main stem thrombosis complicating percutaneous coronary angioplasty. We focused on the issue of dealing with emboli in the non-culprit vessel, as embolism in the "virgin" vessel is often associated with severe cardiogenic shock. We describe the use of a FilterWire technique to protect the non-culprit vessel and a case in which the FilterWire was occluded by thrombus leading to shock. The third case illustrates the difficulty with FilterWire protection if stenting is required in the left main stem itself.

Background: Stents are now widely used in Hong Kong and China and there is a clinical impression that restenosis is less common because of the lower prevalence of coronary artery disease and associated risk factors in the Chinese. However, there are no published data on angiographic stent restenosis rates in Chinese patients., Method: In a prospective study of 114 consecutive Chinese patients who underwent coronary stenting, quantitative coronary analyses were made at the time of stent implantation and subsequently at 6 months post-stenting (n = 97)., Results: At 6 months, restenosis (> or = 50% diameter stenosis in the dilated segment) was present in 42 (43.3%) of the 97 patients and 54 (33.5%) of the total 161 lesions stented. Vessel reference diameter (VRD) of < 3 mm and stented length of > or = 18 mm were associated with higher restenosis rates (36% and 38%). Compared to those without, those with restenosis had a greater residual stenosis of 16.53+/-11.54% and smaller final minimal luminal diameter (MLD) of 2.41+/-0.49 mm, (p < 0.01 and p < 0.008 respectively). Standard coronary risk factors were not associated with a higher rate of restenosis. Lesion morphology was significantly associated with restenosis., Conclusion: Coronary stenting in Hong Kong Chinese patients is associated with a restenosis rate comparable to that demonstrated in previously published trials from populations in the West.

The success rate of percutaneous recanalization of chronic total occlusion remains low. The Safe-Cross wire, which utilizes the principle of optical coherent reflectometry for guidance and has the ability to deliver radiofrequency energy for tissue ablation, was evaluated in 21 patients. This wire was used only after conventional guidewire failure, except in 4 patients who had failed an interventional procedure 3 months to 2 years previously. Conventional guidewires were successful in 9, and the Safe-Cross wire was successful in 10 of the remaining 12, including those 4 with a failed previous attempt. The total success rate was 90% (19/21 patients). Technological improvement in the steerability of the Safe-Cross wire may help to improve the success rate further.