Paso a Paso

3- Disección Subintimal Anterógrada con Reentrada

Dr. Ricardo Santiago Trinidad

MD – San Juan, Puerto Rico – PCI Cardiology Group Puerto Rico , San Juan

El principio fundamental de esta técnica es utilizar el espacio subintimal como puente de la oclusión para luego reentrar más adelante en el lumen verdadero distal. Es utilizada en lesiones que presenten un muñón bien definido y claro, con oclusiones de más de 20 mm de largo, con vaso distal (Target) de buen calibre y que no tenga ramas grandes en el sitio donde se quiera recruzar7.

 

Esto se logra utilizando varias técnicas una de las cuales, la más utilizada es la técnica de guía llamada “acodada” o knucle. Se utiliza acodando una guía hidrofilia del tipo Fielder XT® (Asahi Intecc) o una Pilot 200® (Abbott Vascular). Se avanza logrando hacer un plano de disección controlado sin peligro de perforación. Una vez se logra estar paralelo al lumen verdadero distal a la oclusión, se reentra al lumen utilizando una guía hidrofílica o no hidrofílica de mediano - alto gramaje como la Pilot 200® o la Confianza pro 12® 7.

 

Otra forma de reentrar es con dispositivos como el sistema “Bridgepoint” (BSC) que consiste de un balón plano llamado Stingray®, un catéter de disección roma llamado crossboss y una guía dedicada de alta penetración. El catéter de disección roma llamado crossboss permite crear el mismo efecto que la técnica de guía “acodada” y navegar de una forma más predecible a través del espacio subintimal, para luego inflar el balón Stingray®, el cual presenta dos lúmenes opuestos para permitir reentrar con más versatilidad al lumen verdadero con la guía de alta penetración suministrada en el kit 8. Este dispositivo es ahora uno de los pilares para el tratamiento de las OTC por vía anterógrada en países de Europa y Estados Unidos, cuando se define la ruta anterógrada de disección – reentrada 9.

 

La escuela japonesa no es muy amiga de realizar la ruta de disección subintimal reentrada a diferencia de las escuelas Europeas y Norte Americanas y solo la utilizan como un último recurso 9. Como primera opción la escuela Japonesa recomienda navegar en el lumen verdadero, en lo que ellos llaman loose tissue tracking o intentional intimal tracking 10, y utilizar guías de gramaje bajo (1 gr) con punta hidrofílica como la Fielder XT® , o como la familia de las guías Sion® y la Gaia® (Asahi, Intecc, Japon) que son guías especializadas para ayudar a estar en el lumen verdadero 5,10.

 

Existen otras técnicas ya no tan utilizadas hoy en día como la técnica de STAR (Subintimal Tracking and Re-entry) en donde se realiza disección subintimal extensa con guías suaves o intermedias en forma de “codo” y la guía espontáneamente re-entra al lumen verdadero cuando encuentra el sitio de una bifurcación. Esta técnica ya no se utiliza por la extensa área de disección con compromiso y oclusión de las ramas adyacentes cuando se implantan los stents, por ende, mayor grado de isquemia residual e infarto peroperatorio.

 

Existe también la técnica de LAST (Limited Antegrade Subintimal Tracking) en donde a diferencia de la técnica de STAR, con guías de más alto gramaje se busca re-entrar al lumen verdadero en el sitio y punto elegido por el operador 7. Últimamente se promueve la técnica de Carlino modificada como opción en casos con tortuosidad severa, calcificación o en tercios distales donde con las otras opciones no se logra reentrar. Consiste en inyectar contraste suavemente a través del microcatéter con la idea que se vea el lumen más claramente y de esa manera lograr visualizar la anatomía donde se encuentra el microcatéter, y en algunas ocasiones incluso lograr entrar al lumen verdadero por medio de los micro canales que se tiñen con el contraste 11, 12.

 

Conclusión

La técnica de recanalización anterógrada continúa siendo una de las técnicas más utilizadas para la recanalización de las oclusiones totales crónicas. Con el advenimiento de dispositivos como el Crossboss® y el balón Stingray® (BSC, Mass, USA), ha hecho que la técnica de disección reentrada sea más rápida y sencilla. Sin embargo, en Latinoamérica, debido a costos, el uso de técnicas como LAST (Limited Antegrade Subintimal Tracking) continúa siendo un recurso importante en los servicios de hemodinamia de nuestros países. El conocimiento de los algoritmos para la recanalización anterógrada son claves y determinantes para saber con qué estrategias se debe tratar la oclusión.

 

Referencias Bigliográficas

  1. Alaswad K., Toolbox and Inventory Requirements for Chronic Total Occlusion Percutaneous Coronary Interventions. Interventional Cardiology Clinics. 2012;1(3):281-97.
  2. Garcia S, Abdullah S, Brilakis ES. Chronic total occlusions: patient selection and overview of advanced techniques. Curr Cardiol Rep. 2013;15(2):334.
  3. Thompson CA. The Hybrid Approach for Percutaneous Revascularization of Coronary Chronic Total Occlusions. Interventional Cardiology Clinics. 2012;1(3):349-53.
  4. Brilakis ES, Grantham JA, Karmpaliotis D, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5(4):367-79.
  5. Yamane M. Current Percutaneous Recanalization of Coronary Chronic Total Occlusion. Revista Española de Cardiología (English Edition). 2012;65(3):265-77.
  6. Sianos G, Werner GS, Escaned J, et al. Recanalisation of chronic total coronary occlusions: 2012 consensus document from the EuroCTO club. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2012;8(1):139-45.
  7. Wyman RM. Antegrade Dissection and Reentry. Interventional Cardiology Clinics. 2012;1(3):315-24.
  8. Whitlow PL, Burke MN, Brilakis ES, et al. Use of a novel crossing and re-entry system in coronary chronic total occlusions that have failed standard crossing techniques: results of the FAST-CTOs (Facilitated Antegrade Steering Technique in Chronic Total Occlusions) trial. JACC Cardiovasc Interv. 2012;5(4):393-401.
  9. Touma G, Ramsay D, Weaver J. Chronic total occlusions — Current techniques and future directions. IJC Heart & Vasculature. 2015;7:28-39.
  10. Sumitsuji S, Inoue K, Ochiai M, et al. Fundamental wire technique and current standard strategy of percutaneous intervention for chronic total occlusion with histopathological insights. JACC Cardiovasc Interv. 2011;4(9):941-51.
  11. Carlino M, Ruparelia N, Brilakis ES, et al. Modified contrast microinjection technique to facilitate chronic total occlusion recanalization. Catheter Cardiovasc Interv. 2016;87(6):1036-41.
  12. Amsavelu S, Carlino M, Brilakis ES. Carlino to the rescue: Use of intralesion contrast injection for bailout antegrade and retrograde crossing of complex chronic total occlusions. Catheterization and Cardiovascular Interventions. 2016;87(6):1118-23.

En esta edición

Artículo de Revision

Indicaciones actuales de revascularización de OTC

Dr. Mario Araya Hormazábal
Paso a Paso

Técnicas de Abordaje de una OTC

Dr. Alexandre Schaan de Quadros
Paso a Paso

1- Algoritmo Híbrido

Dr. Alexandre Schaan de Quadros
Paso a Paso

2- Abordaje Anterógrado con Escalamiento de Guías

Dr. Carlos Esteban Uribe
Paso a Paso

3- Disección Subintimal Anterógrada con Reentrada

Dr. Ricardo Santiago Trinidad
Paso a Paso

5- Abordaje Retrógrado

Dr. João Eduardo Tinoco de Paula
Paso a Paso

6- Manejo de complicaciones en el abordaje de OTC

Dr. José De la Torre A
Entrevista con los Expertos

Situación de la revascularización de OTC en Latinoamérica

Dr. Lucio Padilla
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