The hydrophilic guidewire: the poor man's laser for chronic total coronary occlusions for the good and for the bad

Recent trends in the percutaneous treatment of chronic total coronary occlusions

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has a lower success rate than PCI for non-CTO lesions. We sought to determine trends in the treatment of CTOs within the current interventional era. Using 4 sequential recruitment waves of the National Heart, Lung, and Blood Institute Dynamic Registry, we assessed the relative prevalence and success rates in treating CTO (n=371) versus non-CTO (n=4,802) lesions over a 7-year period (1997 to 2004). Characteristics of attempted lesions and factors associated with PCI outcome were evaluated. CTO lesion attempts decreased by 41% over time, from 9.6% (1997 to 1998) to 5.7% (2004, p<0.0001 for trend). More contemporary CTO lesions were longer (22.4 vs 17.0 mm, p=0.006 for trend), had thrombus less often (21.3% vs 35.4%, p=0.03 for trend), and were more often treated with stents (69.8% vs 45.4% p=0.02). The rate of successful intervention for CTO lesions decreased nonsignificantly during this time, from 79.7% to 71.4% (p=0.18). Using multivariable analysis, female gender (adjusted odds ratio 0.42, 95% confidence interval 0.20 to 0.88, p=0.02), and thrombus (adjusted odds ratio 0.31, 95% confidence interval 0.15 to 0.61, p=0.0008) were associated with higher success rates, whereas the presence of severe noncardiac disease (adjusted odds ratio 1.91, 95% confidence interval 1.05 to 3.45, p=0.03) was associated with a higher risk for PCI failure. Recruitment wave and patient age were not independently related to lesion success. In conclusion, during the PCI period of 1997 to 2004, CTO lesions were attempted less frequently and success rates did not increase, indicating a need for new operator techniques or device technologies to treat this important lesion subset by a percutaneous approach.

Influence on collateral flow of recanalising chronic total coronary occlusions: a case-control study

OBJECTIVE

To assess the effect of recanalisation on collateral flow in a case-control study in patients with and without chronic total coronary occlusions.

DESIGN

In 54 patients undergoing percutaneous transluminal coronary angioplasty (PTCA) (mean (SD) age 61 (6) years), coronary collateral flow was measured by intracoronary pressure or Doppler guide wires at the end of repeated balloon occlusions. Coronary collateral flow index (collateral flow relative to normal antegrade flow) during the first two balloon inflations in 27 patients with a chronic total occlusion (occlusion group) was compared with that of 27 patients matched for age, sex, and collateral flow index at the first occlusion and with a coronary artery diameter stenosis </= 80% (stenosis group).

RESULTS

Following revascularisation, collateral flow index decreased in 17 of the patients in the occlusion group (63%) and in eight of the patients in the stenosis group (30%) (p = 0.03 between groups). The overall change of collateral flow index between the first and the second balloon occlusion was -0.04 (0.01) in the occlusion group (p = 0.07 for paired comparison; from 0.29 (0.17) to 0.25 (0.14)), and +0.02 (0.06) in the stenosis group (p = 0.06 for paired comparison; from 0.27 (0.13) to 0.30 (0.15)). The trend to collateral enhancement in the stenosis group differed significantly from the occlusion group (p = 0.01).

CONCLUSIONS

While repeated coronary balloon occlusions induce collateral recruitment in the majority of patients with moderate stenoses, recanalisation of chronic total coronary occlusions is more often associated with collateral flow reduction. A later decrease in collateral flow by involution of collateral channels cannot be excluded by this study but has not been reported so far.

Recanalization of chronic total coronary occlusions: the impact of a new specific guidewire on primary success rate

BACKGROUND: Although chronic total occlusions are encountered frequently in patients with coronary artery disease, an effective strategy to deal with them has yet to be devised. Various new guidewires have been designed in an attempt to negotiate chronic occlusions successfully. The authors have analysed the impact of the Athlete guidewire on procedural success in this lesion subset. METHODS: Sixty-two consecutive patients undergoing percutaneous intervention for chronic total occlusions over a two-year period were retrospectively studied. For the initial attempt, conventional guidewires were used. In case of failure, further attempts were made using the Athlete guidewire. Procedural success rates with the use of conventional and Athlete guidewires were assessed. RESULTS: Failure of the first attempt with the conventional guidewire occurred in 32 (51.6%) patients and success was achieved in 30 (48.4%) patients. In the former patients, a second attempt was made using the Athlete guidewire to cross the occlusion. The second attempt was successful in 20 patients (60%) in whom the first attempt was unsuccessful, while in the remaining 12 (40%) patients the occlusion could not be crossed even during the second attempt and the procedure was then terminated. Following the use of the Athlete guidewire, the success rate increased to 62% (p < 0.001). No complication occurred during the first attempt, while one patient had a coronary perforation using the Athlete guidewire, which was managed successfully without the need for bypass surgery. CONCLUSION: The use of the Athlete guidewire is feasible and safe, and enhances the chances of successfully treating chronic total occlusions during percutaneous coronary revascularization procedures.

Initial experience with a hydrophilic-coated guidewire for recanalization of chronic coronary occlusions

Chronic coronary occlusions are still a therapeutic challenge to the interventional cardiologist. New techniques such as laser wire have improved recanalization rates, but outcomes are still far from satisfactory. We report the results of a nonrandomized single-center investigation using a hydrophilic-coated guidewire (Terumo Crosswire). Between September 1996 and September 1998, 107 chronic occlusions in 106 patients were approached when previous attempts with conventional guidewires failed. Median occlusion duration in these cases was 4 months (range, 0.5-122); mean occlusion length was 19 +/- 11 mm (range, 5-60). Forty-five (42%) of these attempts were successful. Attempts were successful in 42% in the left anterior descending artery, in 30% in the left circumflex artery, in 48% in the right coronary artery, and in 43% in coronary artery bypass grafts. Success rates ranged from 56% for occlusions of less than 4-month duration to 18% for occlusions of more than 36-month duration. The success rate in TIMI 1-flow lesions was significantly higher than in TIMI 0 flow lesions, 85% vs. 36%. In a multivariate regression analysis, TIMI flow grade and occlusion age were independent predictors of success. There were no deaths or Q-wave myocardial infarctions; two cases of hemopericardium were treated successfully. In five cases, pericardial contrast staining due to vessel perforation occurred. Our results indicate that the Crosswire is an effective tool in the treatment of chronic coronary occlusions, even when recanalization attempts with conventional guidewires fail. Cathet. Cardiovasc. Intervent. 49:45-50, 2000.