Use of the crossboss catheter in coronary chronic total occlusion due to in-stent restenosis

Antegrade Dissection and Reentry as Part of the Hybrid Chronic Total Occlusion Revascularization Strategy

Background—

Development of the CrossBoss and Stingray devices for antegrade dissection and reentry (ADR) of chronic total occlusions has improved historically suboptimal outcomes. However, the outcomes, safety, and failure modes of the technique have to be studied in a larger patient cohort. This preplanned substudy of the RECHARGE registry (Registry of CrossBoss and Hybrid Procedures in France, the Netherlands, Belgium and United Kingdom) aims to evaluate the value and use of ADR and determine its future position in contemporary chronic total occlusion intervention.

Methods and Results—

Patients were selected if an ADR strategy was applied. Outcomes, safety, and failure modes of the technique were assessed. The ADR technique was used in 23% (n=292/1253) of the RECHARGE registry and was mainly applied for complex lesions (Japanese chronic total occlusion score=2.7±1.1). ADR was the primary strategy in 30% (n=88/292), of which 67% were successful. Bail-out ADR strategies were successful in 63% (n=133/210). The Controlled ADR (ie, combined CrossBoss-Stingray) subtype was applied most frequently (32%; n=93/292) and successfully (81%; n=75/93). Overall per-lesion success rate was 78% (n=229/292), after use of additional bail-out strategies. The inability to reach the distal target zone (n=48/100) or to reenter (n=43/100) most commonly led to failure. ADR-associated major events occurred in 3.4% (n=10/292).

Conclusions—

Although mostly applied as a bail-out strategy for complex lesions, the frequency, outcomes, and low complication rate of the ADR technique and its subtypes confirm the benefit and value of the technique in hybrid chronic total occlusion percutaneous coronary intervention, especially when antegrade wiring or retrograde approaches are not feasible.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT02075372.

Initial clinical experience of CrossBoss catheter for in-stent chronic total occlusion lesions: A case report

BACKGROUND

The CrossBoss coronary chronic total occlusion (CTO) crossing catheter has been demonstrated to have greatly improved the success rate of crossing CTO lesions, but there are no published data on its application for in-stent CTO lesions.

METHODS

In the current study, we retrospectively reviewed the clinical data of 8 patients with in-stent CTO lesions that were managed with the CrossBoss catheter and herein we report the efficacy and safety of the CrossBoss crossing and re-entry system for this clinically challenging condition.

RESULTS

The CrossBoss catheter was used for 8 patients with in-stent CTO lesions, which resulted in success in 6 cases and failure in 2 cases, with a 75% success rate. Of the 6 patients with successful treatment, 5 cases had the occlusive lesions crossed with the CrossBoss catheter through a proximal lumen-to-distal lumen approach, whereas the remaining case had his occlusive lesions penetrated by the CrossBoss catheter and the guidewire. Two cases failed in treatment as the CrossBoss catheter could not cross the occlusive lesions. The 6 cases with successful treatment included 3 cases with occlusive lesions in the left anterior descending artery, 1 case with occlusive lesions in the obtuse marginal branches, and 2 cases with occlusive lesions in the right coronary artery, and the 2 cases with failure in treatment had their occlusive lesions in the right coronary artery. In addition, patients with a higher Japan chronic total occlusion score were found to have a lower success rate of crossing the occlusive lesions. None of the patients developed complications.

CONCLUSION

Our study demonstrates that the CrossBoss catheter has a high success rate and is safe for in-stent CTOs and can be recommended for this rather clinically challenging condition.

Use of antegrade dissection re-entry in coronary chronic total occlusion percutaneous coronary intervention in a contemporary multicenter registry

BACKGROUND

We assessed efficacy and safety of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using antegrade dissection re-entry (ADR).

METHODS

We examined outcomes of ADR among 1313 CTO PCIs performed at 11 US centers between 2012-2015.

RESULTS

84.1% of patients were men. Prevalence of prior coronary artery bypass graft surgery was 34.3%. Overall technical and procedural success were 90.1% and 88.7%, respectively. In-hospital major adverse cardiovascular events (MACE) occurred in 31 patients (2.4%). ADR was used in 458 cases (34.9%), and was the first strategy in 169 cases (12.9%). ADR cases were angiographically more complex than non-ADR cases (mean J-CTO score: 2.8±1.2 vs. 2.4±1.2, p<0.001). ADR was performed using the CrossBoss catheter in 246 of 458 (53.7%) and the Stingray system in 251 ADR cases (54.8%). Compared with non-ADR cases, ADR cases had lower technical (86.9% vs. 91.8%, p=0.005) and procedural success (85.0% vs. 90.7%, p=0.002), but similar risk for MACE (2.9% vs. 2.2%, p=0.42). ADR was associated with longer procedure and fluoroscopy time, and higher patient air kerma dose and contrast volume (all p<0.001). After excluding retrograde cases, ADR and antegrade wire escalation (AWE) had similar technical success (92.7% vs. 94.2%, p=0.43), procedural success (91.8% vs. 94.1%, p=0.23), and MACE (2.1% vs. 0.6%, p=0.12).

CONCLUSIONS

ADR is used relatively frequently in contemporary CTO PCI, especially for challenging lesions and after failure of other strategies. ADR is associated with similar success rates and risk for complications as compared with AWE, and is important for achieving high procedural success.

Blunt microdissection for endovascular treatment of infrainguinal chronic total occlusions

PURPOSE

To present a systematic safety evaluation of the CrossBoss blunt microdissection catheter for crossing peripheral chronic total occlusions (CTOs).

METHODS

Between July 2010 and July 2011, 15 patients (all men; mean age 60.7±9.1 years) underwent endovascular treatment of 17 infrainguinal CTOs that were resistant to guidewire passage, so the blunt microdissection catheter was employed to recanalize the artery. Fourteen lesions were de novo and 3 were in-stent restenoses. Sixteen lesions were in the superficial femoral artery; 8 of 17 CTOs were TASC II type D. Extensive calcification was present in 12 lesions. Mean lesion length was 182.9±66.2 mm (range 57-296).

RESULTS

Procedural success was 100% and successful crossing without the use of a re-entry device (technical success) was achieved in 15 cases. Twelve lesions were stented. Average fluoroscopy time was 36.5±21.2 minutes (143.8±76.9 Gy*cm (2) radiaton dose area product), during which a mean 172.1±62.2 mL of iodinated contrast were used. Two patients had access site hematomas that were treated conservatively, and there was no perforation, distal embolization, amputation, or need for urgent revascularization. During the mean follow-up of 11.4±0.1 months, 1 patient died, and none required an amputation or surgical revascularization. There was a significant improvement in ankle-brachial index (0.6±0.1 to 0.8±0.2, p=0.001) and symptoms as assessed by Rutherford class at 1 year. Four of 17 limbs required secondary revascularization procedures within 1 year.

CONCLUSION

The CrossBoss blunt microdissection catheter facilitated successful crossing of CTOs in patients with infrainguinal lesions following unsuccessful guidewire crossing, with an acceptably low rate of periprocedural complications and significant improvement in symptoms.

The efficacy of "hybrid" percutaneous coronary intervention in chronic total occlusions caused by in-stent restenosis: insights from a US multicenter registry

OBJECTIVES

To examine the success and complication rates in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) caused by in-stent restenosis (ISR).

BACKGROUND

PCI for in-stent total occlusive disease has traditionally been associated with low success rates. We sought to examine angiographic and procedural outcomes of patients who underwent CTO PCI due to ISR using the novel "hybrid" algorithm, and compare them with patients with de novo CTOs.

METHODS

We examined 521 consecutive patients who underwent CTO PCI at five high-volume PCI centers in the United States using the "hybrid" approach. Clinical, angiographic, and procedural outcomes were compared between CTOs due to ISR and de novo CTOs.

RESULTS

The target CTO was due to ISR in 57 of 521 patients (10.9%). Compared to patients with de novo CTOs, those with CTO due to ISR had higher frequency of diabetes (56.1% vs. 39.6%, P = 0.02) and less calcification (5.3% vs. 16.2%, P <0.001), but longer occlusion length [38 (29-55) vs. 30 (20-51), P = 0.04]. Technical success in the ISR and de novo group was 89.4% and 92.5% (P = 0.43), respectively; procedural success was 86.0% and 90.3% (P = 0.31), respectively; and the incidence of major adverse cardiac events was 3.5% and 2.2% (P = 0.63), respectively.

CONCLUSIONS

Use of the "hybrid" approach to CTO PCI was associated with similarly high procedural success and similarly low major complication rates in patients with de novo and ISR CTOs.

Advances in the management of coronary chronic total occlusions

Chronic total occlusions (CTOs) have been called "the last frontier" of percutaneous coronary intervention (PCI) due to traditionally low success rates and high risk for restenosis and re-occlusion. Recent advances in equipment and crossing techniques have significantly increased CTO PCI success rates while maintaining low risk of complications. Specifically, the retrograde approach and controlled antegrade dissection and re-entry in conjunction with advanced guidewires and microcatheters have significantly improved procedural success rates. Moreover, the introduction of the "hybrid" approach has created a unified framework for operators to approach CTOs in a systematic and efficient fashion. Finally, drug-eluting stents, especially second generation, have improved long-term patency after CTO PCI.

Exit of CrossBoss between stent struts within chronic total occlusion to subintimal space: Completion of case via retrograde approach with rendezvous in coronary

We present a case of successful percutaneous revascularization of a chronic total coronary occlusion due to in-stent restenosis. The CrossBoss catheter (BridgePoint Medical, Minneapolis, MN, USA) was used initially because it is reported to be effective in this setting with a low risk of exiting occluded stents. To the best of our knowledge, this is the first reported case of a CrossBoss penetrating through stent struts into the subintimal space. The case was completed via the retrograde approach with 'rendezvous in coronary'. <Learning objective: Recognize the potential of the CrossBoss catheter to exit between stent struts within chronic total occlusions. Appreciate the need to check the position of the CrossBoss catheter with respect to stents within a chronic total occlusion. Identify the potential for 'rendezvous in coronary' within the subintimal space with the CrossBoss catheter and a retrograde guidewire.>.

Bailout antegrade coronary reentry with the stingray™ balloon and guidewire in the setting of an acute myocardial infarction and cardiogenic shock

Emergent coronary artery bypass surgery for failed percutaneous coronary intervention (PCI) during acute myocardial infarction (MI) is a bailout strategy that is associated with a high in-hospital morbidity and mortality (7-10%). Innovative strategies to improve the probability of PCI success in this setting are needed. Antegrade coronary re-entry with the Stingray™ balloon and guidewire has been shown to facilitate recanalization of chronic total occlusions in stable patients. We report a case where the Stingray™ device was successfully used as a bailout strategy in the setting of an acute MI complicated by cardiogenic shock.

Subintimal dissection/reentry strategies in coronary chronic total occlusion interventions

Subintimal dissection/reentry techniques are increasingly being used for crossing coronary chronic total occlusions both antegradely (using a knucle wire or the Bridgepoint system) or retrogradely (using the controlled antegrade and retrograde tracking and dissection, and reverse controlled antegrade and retrograde tracking and dissection technique). Subintimal dissection/reentry techniques can increase procedural success rates, but their subsequent clinical outcomes are poorly studied, and they appear to be associated with high rates of in-stent restenosis and repeat target lesion revascularization. In the present review, we describe in detail the chronic total occlusions subintimal dissection/reentry techniques, clarify the related terminology and summarize the published studies in this area and the current gaps of knowledge.