Percutaneous in situ coronary venous arterialization - Report of the firsthuman catheter-based coronary artery bypass

Diffuse coronary artery disease is frequently untreatable by coronary arter y bypass or angioplasty. Many such "no-option" patients have been subjects for trials of angiogenesis using growth factor manipulation or laser injury . We think these novel revascularization strategies are limited by insuffic ient inflow to putative areas of new microvasculature and thus seek a more mechanical solution. We report the use of a catheter-based system for arter ializing the adjacent anterior cardiac vein in a patient with chronic total occlusion of the left anterior descending coronary artery. A composite cat heter system (phased-array ultrasound imaging system mounted on a catheter with extendable nitinol needle) was used to deliver an exchange-length intr acoronary guidewire from the proximal left anterior descending coronary art ery into the parallel anterior interventricular vein. Using standard angiop lasty techniques, a fistula was then constructed from the proximal artery t o the coronary vein using a self-expanding connector. The proximal vein was blocked with a novel self-expanding "blocker," thus precluding "steal" thr ough the coronary sinus and forcing retroperfusion of the anterior wall. Th e procedure was completed without complication, and a follow-up angiogram a t 3 months confirmed continued patency of the arteriovenous connection. Thi s patient, who had severe angina before the procedure, has been asymptomati c for 12 months, Percutaneous in situ venous arterialization may be an effe ctive therapy for diffuse, "untreatable" coronary disease by supplying a ro bust inflow of arterialized blood via retroperfusion to severely ischemic m yocardium.