scholarly journals Antegrade Chronic Total Occlusion Strategies: A Technical Focus for 2020

2020 ◽  
Vol 15 ◽  
Author(s):  
Calum Creaney ◽  
Simon J Walsh
Keyword(s):  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Total Occlusion ◽  
Chronic Total Occlusions ◽  
Initial Strategy ◽  
Percutaneous Coronary ◽  
Probability Of Success ◽  
Procedural Strategy ◽  
Low Probability ◽  
Procedural Success

Chronic total occlusions (CTOs) are common in patients with ischaemic heart disease. In many countries, patients with CTOs are underserved by percutaneous coronary intervention (PCI). One of the barriers to CTO PCI is the technical challenges of these procedures. Improvements in technique and dedicated devices for CTO PCI, combined with advances in procedural strategy, have resulted in a dramatic increase in procedural success and outcomes. Antegrade wiring (AW) is the preferred initial strategy in short CTOs, where the proximal cap and course of the vessel is understood. For many longer, more complex occlusions, AW has a low probability of success. Dissection and re-entry techniques allow longer CTOs and those with ambiguous anatomy to be crossed safely and efficiently, and CTO operators must also be familiar with these strategies. The CrossBoss and Stingray system is currently the primary targeted re-entry device used during antegrade dissection and re-entry (ADR), and there continues to be an evolution in its use to increase procedural efficiency. In contrast to older ADR techniques, targeted re-entry allows preservation of important side-branches, and there is no difference in outcomes compared to intraplaque stenting.

Abstract 2236: Usefulness of 64-Slice Computed Tomography in Patients Undergoing Percutaneous Coronary Intervention of Chronic Total Occlusion

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Alice Ohanessian ◽  
Thierry Lefévre ◽  
Sanjay Sastry ◽  
Yves Louvard ◽  
Pierre Dumas ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Side Branch ◽  
Beta Blockade ◽  
Conventional Coronary Angiography ◽  
Total Occlusion ◽  
Percutaneous Coronary ◽  
Procedural Strategy ◽  
Procedural Success

Background. Despite constant technical advances, percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) remains a challenge with procedural success ranging from 65 to 85% in high volume center. MSCT provides information which cannot be obtained with conventional coronary angiography such as: plaque constitution, calcifications and distribution, route and distal run off. A better knowledge of these parameters may influence the approach to such complex PCI, optimize procedural strategy and success. The aim of our study was to evaluate the usefulness of cardiac CT before PCI of CTO. Methods . All patients with CTO underwent 64-slice CT before the scheduled PCI. We used a scan protocol with 64±0.625mm slice collimation (pitch 0.2), 350 ms (General Electric Lihgtspeed VCT) and 420 ms (Philips Brillance) rotation time and simultaneous (ECG) gating. Patients with heart rates above 65 bpm received intravenous beta-blockade. All CT examinations were performed with retrospective electrocardiogram gating. Exclusion criteria were atrial fibrillation and creatinemia >140 μmol/l. Results . Sixty patients were included in the study. Mean age was 63.58.5 yrs, 90% were male. On MSCT, the occlusion length was 25.5mm16.5 (33.119.8 on angiography). Calcifications were evaluated as minimal in 42% (26% angio), moderate in 42% (54%) and severe in 1% (12%) of the cases. No calcification was found in 15% (8%). A possible coronary route was identified in 68% (18% on angio), the lumen was relatively visible in 77%, acceptable in 23% and eccentric in 98%. One side branch was observed in 62 %, two in 8% and none in 30% of the CTO. Procedural difficulty was assessed by angio using a scale of 1 (very easy) to 5 (extremely difficult) with a mean rate of 3.540.92 falling to 2.620.81 after reading the MSCT data. MSCT was deemed as extremely useful in 80%, useful in 18% and non useful in 2%. Overall procedural success was achieved in 79% of the CTOs. Conclusion . MSCT appears to be a new tool for optimising procedural strategy and increasing success rate in CTO angioplasty.

scholarly journals Percutaneous Treatment of Coronary Chronic Total Occlusion Part 2: Technical Approach

2014 ◽  
Vol 9 (3) ◽  
pp. 201 ◽  
Author(s):  
Alfredo Galassi ◽  
Aaron Grantham ◽  
David Kandzari ◽  
William Lombardi ◽  
Issam Moussa ◽  
...  
Keyword(s):  
Chronic Total Occlusion ◽  
Guide Wire ◽  
Coronary Intervention ◽  
Percutaneous Treatment ◽  
Total Occlusion ◽  
Guide Catheter ◽  
Percutaneous Coronary ◽  
Procedural Strategy ◽  
Procedural Success

Dual injection is recommended for nearly all chronic total occlusion (CTO) percutaneous coronary intervention (PCI) to determine the optimal crossing strategy and guide wire advancement into the distal true lumen. Strategies that provide enhanced guide catheter support (such as long sheaths, large-bore guiding catheters, use of guide catheter extensions, and anchor techniques) are important for maximising the success rate and efficiency of CTO PCI. Use of a microcatheter or over-the-wire balloon is strongly recommended in CTO PCI for enhancing the penetrating power of the guidewire, enabling change in tip shape and allowing guidewire change (stiff CTO guidewires are not optimal for crossing non-occluded coronary segments). Adherence to a procedural strategy that standardises CTO technique and facilitates procedural success is recommended. Such a strategy would permit stepwise decision-making for antegrade and retrograde methods; inform guidewire selection; and incorporate alternative approaches for instances of initial failure. Given the paucity of long-term outcomes with use of novel crossing techniques (antegrade dissection/re-entry and retrograde), antegrade wire escalation is the preferred CTO crossing technique, if technically feasible. Using measures to minimise radiation exposure (including but not limited to use of 7.5 frames per second fluoroscopy and use of low magnification) and contrast administration is recommended. CTO PCI is best performed at centres with dedicated CTO PCI experience and expertise. Use of crossing difficulty prediction tools, such as the J-CTO score, can facilitate the selection of cases with a high likelihood of quick crossing that can be attempted at less experienced centres.

Chronic total occlusions

2018 ◽  
pp. 315-336
Author(s):  
Colm G. Hanratty ◽  
James C. Spratt ◽  
Simon J. Walsh
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Clinical Indication ◽  
Success Rates ◽  
Total Occlusion ◽  
Chronic Total Occlusions ◽  
Percutaneous Coronary ◽  
Set Up

Chronic total occlusion (CTO) of a coronary artery remains one of the most challenging scenarios in cinical practice. There is much debate about whether opening a CTO is clinically indicated and the procedures are often considered too risky. As a result many patients with a clinical indication for percutaneous coronary intervention (the presence of angina despite medical therapy, with proven ischaemia and viability) are not offered treatment. This chapter will aim to demystify the procedure by explaining how pathophysiological features can help understand the anatomy and how cath lab set-up can increase procedural efficiency, safety, and overall success rates. There are four methods by which a CTO can be opened and we will describe these methods and the anatomically salient features to help select the most appropriate method with which to start.

P1964Impact of successful coronary intervention for chronic total occlusion on long-term clinical outcome of patients with impaired and preserved left ventricular ejection fraction

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
H Tanaka ◽  
T Tada ◽  
Y Fuku ◽  
T Goto ◽  
K Kadota
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Total Occlusion ◽  
Ventricular Ejection Fraction ◽  
Percutaneous Coronary ◽  
Procedural Success

Abstract Background Successful recanalisation of percutaneous coronary intervention for chronic total occlusion lesions has been associated with improved survival. Purpose This study aimed to assess the impact of successful percutaneous coronary intervention for chronic total occlusion lesions on the long-term outcome of patients with impaired and preserved left ventricular ejection fraction (LVEF). Methods The study sample consisted of 842 consecutive patients (928 chronic total occlusion lesions) undergoing percutaneous coronary intervention at our institution between October 2005 and December 2009. We divided them into 3 groups by the degree of LVEF: less than 40% (severely reduced LVEF, n=140), 40% to 59% (moderately reduced LVEF, n=470), and 60% and above (normal LVEF, n=232). We evaluated mortality during the 10-year follow-up period the basis of procedural success and failure. Results The overall procedural success rate was 89.1%. Median follow-up duration was 7.9 years. The 10-year cumulative incidences of cardiac death in each degree of LVEF are shown in the Figure. Conclusions Successful recanalisation for chronic total occlusion lesions in patients with impaired LVEF may be associated with reduced cardiac mortality.

The Impact of Peripheral Artery Disease in Chronic Total Occlusion Percutaneous Coronary Intervention (Insights From PROGRESS-CTO Registry)

Angiology ◽  
2019 ◽  
Vol 71 (3) ◽  
pp. 274-280 ◽  
Author(s):  
Iosif Xenogiannis ◽  
Fotis Gkargkoulas ◽  
Dimitri Karmpaliotis ◽  
Khaldoon Alaswad ◽  
Oleg Krestyaninov ◽  
...  
Keyword(s):  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Peripheral Artery ◽  
Total Occlusion ◽  
Percutaneous Coronary ◽  
History Of ◽  
Artery Disease ◽  
Procedural Success ◽  
The Impact ◽  
Complex Lesions

The impact of peripheral artery disease (PAD) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We reviewed 3999 CTO PCIs performed in 3914 patients between 2012 and 2018 at 25 centers, 14% of whom had a history of PAD. We compared the clinical and angiographic characteristics and procedural outcomes of patients with versus without history of PAD. Patients with PAD were older (67 ± 9 vs 64 ± 10 years, P < .001) and had a higher prevalence of cardiovascular risk factors. They also had more complex lesions as illustrated by higher Japanese CTO score (2.7 ± 1.2 vs 2.4 ± 1.3, P < .001). In patients with PAD, the final crossing technique was less often antegrade wire escalation (40% vs 51%, P < .001) and more often the retrograde approach (23 vs 20%, P < .001) and antegrade dissection/reentry (20% vs 16%, P < .001). Technical success was similar between the 2 study groups (84% vs 87%, P = .127), but procedural success was lower for patients with PAD (81% vs 85%, P = .015). The incidence of in-hospital major adverse cardiac events was higher among patients with PAD (3% vs 2%, P = .046). In conclusion, patients with PAD undergoing CTO PCI have more comorbidities, more complex lesions, and lower procedural success.

scholarly journals Tips and Tricks for PCI of Chronic Total Occlusions – A Review

2021 ◽  
Vol 02 (01) ◽  
pp. 031-041
Author(s):  
Rohit Mody
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Success Rate ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Tips And Tricks ◽  
Total Occlusion ◽  
Chronic Total Occlusions ◽  
Antegrade Approach ◽  
Complex Patients ◽  
Percutaneous Coronary

Chronic total occlusion recanalization still represents the final frontier in percutaneous coronary intervention. Retrograde recanalization is one of the greatest amendments of this technique. At present, it has become an integral complement to the traditional antegrade approach. Despite being most frequently used in complex patients, it has the highest success rate with the lowest incidence of complications. Since its inception, significant iterations have occurred that made this technique safer, faster, and even more successful.

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