Conventional vascular access site approach versus fully trans-wrist approach for chronic total occlusion percutaneous coronary intervention: a multicenter registry

Global Consensus Recommendations on Improving the Safety of Chronic Total Occlusion Interventions

Safety is of critical importance to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). This global consensus statement provides guidance on how to optimise the safety of CTO) PCI, addressing the following 12 areas: 1. Set-up for safe CTO PCI; 2. Guide catheter--associated vessel injuries; 3. Hydraulic dissection, extraplaque haematoma expansion, and aortic dissections; 4. Haemodynamic collapse during CTO PCI; 5. Side branch occlusion; 6. Perforations; 7. Equipment entrapment; 8. Vascular access considerations; 9. Contrast-induced acute kidney injury; 10. Radiation injury; 11 When to stop; and, 12. Proctorship. This statement complements the global CTO crossing algorithm; by advising how to prevent and deal with complications, this statement aims to facilitate clinical practice, research, and education relating to CTO PCI.

Performance of the minimalistic hybrid approach algorithm versus other conventional algorithms in the percutaneous treatment of chronic total occlusions

BACKGROUND

The "Minimalistic Hybrid Approach" (MHA) has been proposed to reduce the invasiveness of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

AIMS

This study aims to assess whether MHA may also reduce the utilization of PCI resources (devices, radiations, and contrast) by comparing it with other conventional algorithms.

METHODS

We aimed to assess the impact of MHA on device, radiation, and contrast usage during CTO-PCI analyzing data from the Belgian Working Group on CTO (BWG-CTO) registry. Patients were divided, depending on the algorithm used, into two groups: Conventional versus Minimalistic. Primary objectives were procedure performance measures such as device usage (microcatheters and guidewires), radiological parameters, and contrast use. At 1-year follow-up, patients were evaluated for target vessel failure (TVF), defined as a composite of cardiac death, new myocardial infarction, and target vessel revascularization.

RESULTS

Overall, we analyzed 821 CTO-PCIs (Conventional n = 650, Minimalistic n = 171). The Minimalistic group demonstrated higher complexity of CTO lesions. After adjusting for propensity score, the Minimalistic group had a significantly lower number of microcatheters used (1.49 ± 0.85 vs. 1.24 ± 0.64, p = 0.026), while the number of guidewires was comparable (4.80 ± 3.29 vs. 4.35 ± 2.94, p = 0.30). Both groups had similar rates of success and procedural complications, as well as comparable procedural and fluoroscopic times and contrast volume used. At the 1-year follow-up, both groups showed comparable rates of TVF (hazard ratio: 0.57; 95% confidence interval: 0.24-1.34, p = 0.195).

CONCLUSION

The MHA may slightly reduce the number of dedicated devices used during CTO-PCI, without adversely affecting the procedural success or long-term outcome.

Alternative (Transulnar or Distal Radial) Arterial Access for Chronic Total Occlusion Percutaneous Coronary Intervention (Subanalysis from the Minimalistic Hybrid Approach Algorithm Registry)

The transradial approach (TRA) has become the primary choice for percutaneous coronary intervention (PCI); however, it may not be always feasible because of clinical and/or technical challenges. Alternative forearm accesses, such as transulnar approach (TUA) and distal radial approach (dTRA) may allow maintaining a wrist approach for the procedure, avoiding the femoral artery. This issue is particularly relevant in patients who underwent multiple revascularizations, such as those with chronic total occlusion (CTO) lesions. This study aimed to evaluate whether the use of TUA and/or dTRA is comparable with TRA in CTO PCI using a minimalistic hybrid approach algorithm, which limits the number of accesses used to minimize vascular access complications. Patients with CTO PCI treated solely through a fully alternative approach (TUA and/or dTRA) were compared with those treated solely through a standard TRA approach. The primary efficacy end point was procedural success, whereas the primary safety end point was the composite of major adverse cardiac and cerebral events and vascular complications. Of 201 CTO PCIs attempted, 154 procedures were considered for analysis (standard, n = 104, alternative, n = 50). Alternative and standard groups demonstrated comparable rates of both procedural success (92% vs 94.2%, p = 0.70) and primary safety end point (4.8% vs 6.0%, p = 0.70). Of interest, 7 French guiding catheters were more frequently used in the alternative group (44% vs 26%, p = 0.028). In conclusion, CTO PCI after minimalistic hybrid approach by way of alternative forearm vascular accesses (dTRA and/or TUA) is feasible and safe to perform, compared with CTO PCI by way of standard TRA.

Meta-Analysis on the Safety and Efficacy of Transradial Approach in Chronic Total Occlusion Percutaneous Coronary Intervention

The aim of this study was to compare the efficacy and safety of transradial approach (TRA) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with the efficacy and safety of transfemoral approach (TFA). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies (OS) reporting the outcomes of TRA versus TFA in CTO PCI. The primary end point was procedural success. Secondary end points included access-site complications, in-hospital adverse events, procedural efficacy outcomes, and 30-day all-cause mortality. A total of 28,754 CTO PCI cases from 19 studies were included (2 RCTs and 17 OS). The pooled mean J-CTO score is 2.3. The main analysis showed a trend toward a higher success rate for TRA (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.00 to 1.38), but this was not the case in the secondary analysis, which included only RCTs and OS with moderate risk of bias (OR 0.99, 95% CI 0.81 to 1.22). TRA was associated with significant reductions in access-site complications (OR 0.33, 95% CI 0.24 to 0.45) and major bleeding (OR 0.34, 95% CI 0.20 to 0.59), and a similar risk of other in-hospital adverse events and 30-day mortality (p >0.05) to that of TFA. Moreover, there was less fluoroscopy time (minutes) and contrast volume use (ml) in the transradial CTO PCI (mean difference: -6.19 [-10.98 to -1.40] and -22.14[-34.56 to -9.72], respectively). In conclusion, the transradial PCI in appropriate CTO lesions was associated with a lower incidence of access-site complications/major bleeding than was TFA and a similar other periprocedural complications rate, without compromising procedural success.

Ultrasound versus fluoroscopy-guided femoral access for percutaneous coronary intervention of chronic total occlusions: Insights from FOUND BLOOD CTO Registry

OBJECTIVE

To compare vascular complications in patients undergoing percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) using ultrasound guidance (USG) versus fluoroscopy guidance (FSG) for femoral access.

BACKGROUND

In patients undergoing PCI, using the arterial femoral access increases the risk of vascular complications compared using the radial access. USG reduces time to access, number of attempts, and vascular complications compared with FSG, but the efficacy of USG has never been tested in the setting of CTO-PCI.

METHODS

A total of 197 patients undergoing CTO-PCI using at least a femoral vascular access from November 2015 to September 2020 were screened. The primary outcome was a composite of local hematoma, pseudoaneurysm, retroperitoneal hemorrhage, arteriovenous fistula or hemoglobin drop ≥3 g/dL during hospitalization. The independent association between USG and the primary outcome of interest was explored.

RESULTS

The primary outcome occurred in 17.3% of patients. Patients in the USG group had a significantly lower incidence of vascular complications compared with patients in the FSG group (8.5% vs. 21.0%, p = 0.039), driven by a reduction of localized hematomas (3.4% vs 13.0%, p = 0.042). After adjustment for type of CTO approach and heparin dose, USG was significantly associated with a reduced relative risk of the composite primary outcome (adjusted odds ratio 0.16, 95% confidence interval 0.05 to 0.51; p = 0.002).

CONCLUSION

USG in CTO-PCI is associated with a decreased risk of vascular complications, primarily driven by a reduction in local hematomas, especially in complex CTO-PCI where the larger use of heparin increases the risk of vascular complications.

Complications during chronic total occlusion percutaneous coronary intervention: a sign- and symptom-based approach to early diagnosis and treatment

Coronary chronic total occlusions (CTO) are frequently found in patients undergoing coronary angiography. Despite their high prevalence and indication for revascularization in a relevant proportion of cases, CTO recanalization is attempted only in a minority of cases. This is due to higher risk of procedural complications compared to non-CTO interventions and because the CTO-PCIs are the most complex procedures in interventional cardiology. In particular, the perceived higher risk of complications during CTO intervention might discourage new operators from engaging in this challenging field. The aim of this work is to review the potential complications of CTO percutaneous coronary intervention, and to provide an algorithmic, sign- and symptom-based approach to facilitate early recognition and effective management.

Experience with the novel unifemoral parallel sheath technique in percutaneous intervention of chronic total coronary occlusions

Background

Percutaneous interventions to address chronic coronary occlusions (CTO-PCI) often require simultaneous ipsi- and contralateral coronary injections. Although radial access is increasingly popular, bifemoral artery access is still the preferred choice of CTO operators.

The aim of this case series is to demonstrate the feasibility and safety of the unifemoral parallel sheath technique, which avoids two puncture sites, increases patient comfort, and improves procedure ergonomics.

It offers rapid second access to the femoral artery adjacent to the first sheath as well as closure by unilateral manual compression without or with 1 or 2 vascular closure devices.

Results

We retrospectively evaluated the procedure results in 90 consecutive CTO patients where an ipsilateral parallel sheath access was considered. Placement of the second sheath uneventfully failed in two because of severe femoral calcification and narrowing. In 96.6%, the first sheath was 7 F (3.4% 6F), while the second sheath was 4 F in 22.7%, 5 F in 64.7%, and 6 or 7 F in 11.4% each.

No major complications nor severe bleeding events occurred, and the mean drop of hemoglobin was low (0.6 g/dL ± 0.86).

Conclusion

In CTO-PCI requiring contralateral coronary injections or the retrograde technique, the ipsilateral parallel sheath technique might be a feasible alternative to the standard bifemoral or femoral-radial access.