Use of chronic total occlusion percutaneous coronary intervention techniques for treating acute vessel closure

Knuckle wire technique in percutaneous coronary intervention of chronic total occlusion: Knuckle wire technique

In percutaneous coronary intervention, the knuckle wire technique is one of the approaches to cross the long and ambiguous course of the occluded segment. However, this technique is generally used as a last alternative, when all other techniques fail. Although knuckle wiring expedites chronic total occlusion crossing, it can also complicate the percutaneous coronary intervention strategy irreversibly. Therefore, understanding the various aspects of the knuckle wire technique is a prerequisite in a chronic total occlusion setting. The authors herein intend to describe in detail the knuckle wire technique and its safe and effective approach in various chronic total occlusion wiring strategies, while befitting to the scope of a mainstream interventionist.

Salvage of Simultaneous Acute Coronary Closure and Retroperitoneal Bleeding Using Veno-Arterial Extracorporeal Membrane Oxygenation and Chronic Total Occlusion Percutaneous Coronary Intervention Techniques in a Patient with ST-Segment Elevation Myocardial Infarction

Iatrogenic coronary artery dissection is a feared complication of percutaneous coronary intervention as it can potentially lead to severe myocardial ischemia, arrhythmias, shock, and death. Bailout-stenting or less often, emergent coronary artery bypass graft surgery may be needed for restoring antegrade flow. We describe a case of inferior ST-segment elevation acute myocardial infarction with preserved antegrade coronary flow. Percutaneous coronary intervention was complicated by acute right coronary artery closure during guide catheter engagement. Attempts for re-entry into the right coronary artery true lumen failed. Attempts to obtain right femoral arterial access resulted in retroperitoneal hematoma. The patient developed refractory ventricular fibrillation and could not be defibrillated. Veno-arterial extracorporeal membrane oxygenation was started using surgical right femoral cutdown for the venous cannula and the left common femoral artery for the arterial cannula. A dissection strategy with a knuckled guidewire was used around previously placed stents followed by successful re-entry into the distal right coronary artery using the Stingray system. The venous cannula was changed to the internal jugular vein and the right common femoral artery and vein were surgically repaired. The patient was decannulated two days later and was eventually discharged from the hospital neurologically intact.