Long-term Clinical and Angiographic Outcomes of the Mini-STAR Technique as a Bailout Strategy for Percutaneous Coronary Intervention of Chronic Total Occlusion

Wire-based antegrade dissection re-entry technique for coronary chronic total occlusions percutaneous revascularization: Experience from the ERCTO Registry

BACKGROUND

The recent development and widespread adoption of antegrade dissection re-entry (ADR) techniques have been underlined as one of the antegrade strategies in all worldwide CTO consensus documents. However, historical wire-based ADR experience has suffered from disappointing long-term outcomes.

AIMS

Compare technical success, procedural success, and long-term outcome of patients who underwent wire-based ADR technique versus antegrade wiring (AW).

METHODS

One thousand seven hundred and ten patients, from the prospective European Registry of Chronic Total Occlusions (ERCTO), underwent 1806 CTO procedures between January 2018 and December 2021, at 13 high-volume ADR centers. Among all 1806 lesions attempted by the antegrade approach, 72% were approached with AW techniques and 28% with wire-based ADR techniques.

RESULTS

Technical and procedural success rates were lower in wire-based ADR than in AW (90.3% vs. 96.4%, p < 0.001; 87.7% vs. 95.4%, p < 0.001, respectively); however, wire-based ADR was used successfully more often in complex lesions as compared to AW (p = 0.017). Wire-based ADR was used in most cases (85%) after failure of AW or retrograde procedures. At a mean clinical follow-up of 21 ± 15 months, major adverse cardiac and cerebrovascular events (MACCEs) did not differ between AW and wire-based ADR (12% vs. 15.1%, p = 0.106); both AW and wire-based ADR procedures were associated with significant symptom improvements.

CONCLUSIONS

As compared to AW, wire-based ADR is a reliable and effective strategy successfully used in more complex lesions and often after the failure of other techniques. At long-term follow-up, patient's MACCEs and symptoms improvement were similar in both antegrade techniques.

A Novel Parallel Wire-based Antegrade Dissection Re-entry Technique for Failed Retrograde Attempt of Coronary Chronic Total Occlusions with Risk Nomogram Analysis

BACKGROUND

Rapid development in coronary chronic total occlusion (CTO) interventional techniques and devices have achieved a greater success rate with favorable outcomes. Antegrade dissection re-entry (ADR) technique is an important CTO crossing strategy and a desirable approach for long CTOs with good distal landing zone. However, unsuccessful procedures in contemporary CTO-percutaneous coronary intervention (PCI) remain, especially in lesions with non-interventional collaterals.

METHOD

Based on a single center experience, a hybrid interventional algorithm, parallel wire-based ADR (PW-ADR) combines the advantages of parallel wire technique (PWT) and device-based ADR to target CTO lesions with failed retrograde approach. A retrospective analysis of patients who underwent PW-ADR was performed. A risk nomogram was created to identify patients at high risk for technical failure.

RESULTS

A total of 57 patients treated with PW-ADR were ultimately included in the present study. A total of 46 (80.7%) cases achieved technical success and procedural success, with low incidence of in-hospital complications or 1-year major adverse cardiac events (MACE). The risk nomogram identified 3 predictor variables associated with technical failure of PW-ADR, including tortuous vessel, J-CTO score, and times of antegrade coronary angiography (CAG) during ADR, with promising accuracy (AUROC 0.947).

CONCLUSION

The novel hybrid CTO-PCI algorithm, PW-ADR, provided an alternative interventional approach for complex CTO lesions with a promising success rate. The risk nomogram served as a prompter for high-risk cases, which may warrant a change in treatment strategy.

Long term clinical outcome after success re-attempt percutaneous coronary intervention of chronic total occlusion

BACKGROUND

To evaluate the long-term outcome after re-attempt CTO-PCI.

METHODS

This is a retrospective cohort study that included 113 re-attempt CTO-PCI patients who were consecutively registered from January 2019 to December 2020 at Beijing Anzhen Hospital's Center of Coronary Artery Disease. All patients were divided into two groups based on procedural success or failure. The primary endpoint was major adverse cardiac events (MACE), a composite of all-cause mortality, myocardial infarction and target vessel revascularization (TVR). The secondary endpoint was angina after PCI.

RESULTS

Overall, the successful re-attempt CTO-PCI was archived in 77 patients, the failed CTO-PCI was performed in 36 patients. After a median follow-up of 21.7 months (interquartile range: 10.9-26.0), the incidence of the primary outcome was significantly lower in the success group [14.2% vs. 38.9%, adjusted hazard ratio (HR) 0.351, 95% CI 0.134-0.917, P = 0.033], mainly driven by the reduction of TVR (9.1% vs. 30.6%, adjusted HR 0.238, 95% CI: 0.078-0.72, P = 0.011). Furthermore, patients who had successful re-attempt CTO-PCI had a lower risk of angina after PCI (27.3% vs.61.1%, adjusted HR 0.357, 95% CI 0.167-0.76, P = 0.008). The risk factors of TVR in the patients with successful re-attempt CTO-PCI were stent length > 100 mm (adjusted HR 21.805, 95% CI 1.765-269.368, P = 0.016) and J-CTO score > 3(adjusted HR: 9.733, 95% CI:1.533-61.797, P = 0.016).

CONCLUSIONS

For the patients with previous CTO-PCI failure, a successful re-attempt CTO-PCI was associated with significantly lower MACE, which was primarily driven by a lower TVR rate. More complex CTO lesions and longer stents were the independent predictors of TVR after successful CTO-PCI.

Dual guidewire balloon antegrade fenestration and re-entry technique for coronary chronic total occlusions percutaneous coronary interventions

OBJECTIVES

To describe the experience of coronary chronic total occlusions (CTOs) percutaneous coronary interventions (PCI) using antegrade fenestration and re-entry (AFR) technique with a dedicated dual guidewire balloon (DGB).

BACKGROUND

Antegrade dissection and re-entry (ADR) techniques has been emphasized in recent worldwide CTO consensus documents. We investigated the feasibility and safety of DGB as a dedicated device to perform guidewire-based AFR.

METHODS AND RESULTS

Fourteen consecutive patients with complex CTO (J-CTO score: 3.1 ± 0.9) underwent DGB-AFR in the years 2020-2021. DGB-AFR consists in advancing the DGB over a guidewire that reached the vessel distal to the CTO in an extra plaque fashion, inflating/deflating the DGB to create fenestration between subintimal space and the true lumen and advancing a proximal re-entry guidewire through fenestration in the true lumen. DGB-AFR alone was successful in 10 of 14 (71%) cases, a rescue wire-based ADR was needed in two cases for re-entry into the true lumen with a total success rate in 12 of 14 (86%) cases. Among all DGB-AFR cases, four (28%) were performed as a first-line strategy while the remaining 10 (71%) cases were performed as a bail-out strategy after failure of other antegrade crossings for 30 min of procedural time. No DGB-related complications were observed.

CONCLUSIONS

DGB-AFR is a user-friendly reliable strategy for the treatment of many CTO lesions. It can be used as bail-out after failure of conventional antegrade wiring techniques, achieving high procedural success rate and low occurrence of procedural adverse events.

Chronic Total Occlusion Percutaneous Coronary Intervention in Patients With Prior Coronary Artery Bypass Graft: Current Evidence and Future Perspectives

Coronary chronic total occlusion (CTO), which occurs in 18. 4-52% of all patients referred for coronary angiography, represents one of the last barriers in coronary intervention. Approximately half of all patients with prior coronary artery bypass graft (CABG), who undergo coronary angiography, are diagnosed with coronary CTO. In fact, these patients often develop recurrent symptoms and events, necessitating revascularization. Currently, there is neither a consensus nor developed guidelines for the treatment of CTO patients with prior CABG, and the prognosis of these patients remains unknown. In this review, we discuss current evidence and future perspectives on CTO revascularization in patients with prior CABG, with special emphasis on clinical and lesion characteristics, procedural success rates, periprocedural complications, and long-term outcomes.

CTO in Contemporary PCI

Percutaneous Coronary Intervention (PCI) of Chronic Total Occlusions (CTO) represents the most challenging procedure in modern endovascular treatments. In recent years, the success rate of CTO PCI has substantially improved, owing to increasing operator expertise and advancements in CTO equipment and algorithms as well as the development of expert consensus documents. In this review, we summarize existing evidence for CTO PCI, its success/ risk prediction scoring tools, procedural principles and complications and provide an insight into the future role of CTO PCI.

Overview of Contemporary Chronic Total Occlusion Percutaneous Coronary Intervention Techniques: A Narrative Systematic Review

BACKGROUND

Despite the abundance of coronary chronic total occlusions (CTO) percutaneous coronary intervention (PCI) studies, the literature is not easy to digest for both general PCI operators and CTO PCI specialists because of the many varied terms used for approaches and inconsistency in terminology. This inconsistency makes it challenging to understand the advantages and disadvantages of these different approaches and, most importantly, their downstream clinical outcomes. Accordingly, we conducted a systematic review of all published studies on CTO PCI to describe techniques and algorithms used in the last decade to provide an overview on the efficacy and safety of contemporary CTO PCI techniques.

METHODS

We performed a comprehensive search of the PubMed, EMBASE, and the Cochrane library databases for manuscripts about PCI of CTOs. We included studies published between the years 2005 and 2019. We categorized studies into those using a single approach (antegrade, retrograde) and those with a prespecified algorithm (ie, hybrid approach).

RESULTS

Fifty-five observational studies including 28,907 patients who underwent CTO were included in this review. CTO PCI generally carries low risk of major procedural complications, with angiographic success rates being higher in studies that used an algorithmic vs single technical approach.

CONCLUSIONS

This systematic review highlights the wide variation in definitions and practices in CTO PCI and calls for standardization in terminology and practice.

Chronic total occlusion percutaneous coronary intervention in everyday clinical practice - an expert opinion of the Association of Cardiovascular Interventions of the Polish Cardiac Society

Coronary chronic total occlusions (CTO) are increasingly encountered during invasive and non-invasive coronary angiography and remain the most challenging lesions for percutaneous revascularization. During recent years success rates and safety outcomes of CTO percutaneous coronary intervention (PCI) have substantially improved, particularly due to the introduction of new techniques and dedicated equipment as well as specialized training programs of CTO operators. Significantly, the steady advances in CTO PCI techniques have coincided with the new data from randomized clinical trials supporting the role of percutaneous recanalization of CTO in relieving angina and improving the quality of life. The current expert consensus document outlines the rationale, clinical outcomes as well as technical, safety and reimbursement issues of CTO PCI. In addition, the requirements for achieving and maintaining competency in CTO PCI among interventional cardiologists are discussed. Finally, we present the modified hybrid algorithm (the so-called Polish hybrid algorithm) providing some unique refinements to the contemporary CTO PCI strategies. Continuous efforts (including active engagement with the payer) are urgently needed to increase guideline-recommended referrals to CTO PCI, and thus improve the quality of life of CTO patients in Poland.

Subintimal Plaque Modification and Subintimal Dissection and Reentry: Strategies to Turn Failure into Success

The success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) depends on the execution of bailout strategies, like subintimal dissection and reentry (STAR) and subintimal plaque modification (SPM). These are invaluable when traditional techniques fail. SPM is a modification of the STAR technique in which angioplasty is performed of the occluded segment without true lumen access in the distal vessel. Available data on SPM has shown favorable outcomes with a greater than 90% success rate when the failed CTO is reattempted in 8-12 weeks after SPM has been performed. Future studies are needed to better assess its role.

Antegrade Chronic Total Occlusion Strategies: A Technical Focus for 2020

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.

Impact of Specific Crossing Techniques in Chronic Total Occlusion Percutaneous Coronary Intervention on Recovery of Absolute Myocardial Perfusion

Background:

Multiple crossing techniques in chronic total occlusion (CTO) percutaneous coronary intervention have been developed. This study compared recovery of quantitative myocardial blood flow (MBF) after different CTO percutaneous coronary intervention techniques.

Methods:

Consecutive patients with [ 15 O]H 2 O positron emission tomography perfusion imaging before and 3 months after successful CTO percutaneous coronary intervention between 2013 and 2018 were included. Changes in hyperemic MBF, coronary flow reserve, and perfusion defect size were compared between antegrade wire escalation, retrograde wire escalation, antegrade dissection and reentry (ADR), and retrograde dissection and reentry.

Results:

One hundred ninety-three patients were treated with antegrade wire escalation (N=90), retrograde wire escalation (N=24), ADR (N=35), and retrograde dissection and reentry (N=44). Increase in hyperemic MBF (1.19±0.77, 0.94±0.65, 1.09±0.63, and 1.02±0.75 mL·min -1 ·g -1 , respectively; P =0.40) and coronary flow reserve (1.34±1.08, 1.14±1.09, 1.31±0.96, and 1.24±0.99, respectively; P =0.84) and decrease in defect size (3.2±2.1, 3.0±2.2, 2.7±2.1, and 2.9±1.9 segments, respectively; P =0.77) were comparable between the 4 approaches. In addition, recovery of hyperemic MBF was less pronounced after subintimal crossing with knuckle-wire-technique compared with CrossBoss in controlled ADR and retrograde dissection and reentry (0.93±0.69 versus 1.54±0.65 mL·min -1 ·g -1 , P =0.02), and less after reentry using subintimal tracking and reentry in ADR compared with controlled ADR (Stingray) or limited antegrade subintimal tracking (0.60±0.53 versus 1.18±0.54 [ P =0.04] and versus 1.49±0.57 mL·min -1 ·g -1 , [ P <0.01]).

Conclusions:

Recovery of hyperemic MBF, coronary flow reserve, and perfusion defect size after CTO percutaneous coronary intervention was comparable between different approaches. Although sometimes necessary to cross a complex CTO lesion, subintimal knuckle wiring and subintimal tracking and reentry resulted in less hyperemic MBF improvement compared with other subintimal crossing and reentry techniques.

Current approaches for treatment of coronary chronic occlusions

Introduction: Coronary chronic total occlusions (CTO) represent a challenging subset in interventional cardiology.Areas covered: During the last decade, improvements in materials, techniques, and meticulous pre-procedural lesion assessment have increased the success rate in CTO lesions. Several scores have been developed to address overall lesion evaluation and help select the most appropriate treatment strategy. In addition, specific algorithms such as the hybrid algorithm have been introduced to provide a framework for CTO operators and a rapid management of the various challenging aspects of the procedure. The hybrid approach requires operator's ability to switch from one treatment strategy to another when the first one appears to be unsuccessful. Adequate training and operators' experience remain crucial to improve the likelihood of success.Expert opinion: The aim of this review is to provide insights and guidance for operators on current approaches for treatment of CTO and complication management.

Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

A Technical Focus on Antegrade Dissection and Re-entry for Coronary Chronic Total Occlusions: a Practice Update for 2019

Coronary chronic total occlusions (CTOs) are a commonly encountered lesion. These present in a diverse patient population with variable anatomy. Technical success rates of ~90% are achievable for CTO lesions in centers with appropriate expertise. Many lesions can be crossed with wire-based techniques. However, the most anatomically complex and technically challenging lesions will often require more advanced approaches such as retrograde access and/or the application of blunt dissection techniques in the vessel to safely navigate long and/or ambiguous CTO segments. Retrograde dissection and re-entry (RDR) and antegrade dissection and re-entry (ADR) strategies are often needed to treat such lesions. In many circumstances, ADR offers a safe and efficient means to successfully cross a CTO lesion. Therefore, operators must remain cognizant of the risks and benefits of differing technical approaches during CTO percutaneous coronary intervention, particularly when both ADR and RDR are feasible. This article provides an overview of the ADR technique in addition to updated approaches in contemporary clinical practice.

Percutaneous coronary intervention versus optimal medical therapy for patients with chronic total occlusion: a meta-analysis and systematic review

Background

It was under debate whether chronic total occlusion (CTO) patients could benefit from percutaneous coronary intervention (PCI). We sought to compare clinical outcomes of PCI and optimal medical therapy (OMT) in these patients.

Methods

PubMed, Embase and Cochrane Library were searched for studies enrolling patients with CTO who accepted PCI or OMT. The meta-analysis was performed by using a random-effect model. In addition, subgroup analyses were performed, including patients after propensity-matching and patients with CTO in infarct-related artery (IRA), respectively.

Results

We identified 5 studies enrolling 4,761 participants in this meta-analysis. In the main analysis, when compared with OMT, PCI was associated with significant improvement in all-cause death [risk ratio (RR) 0.41, 95% CI: 0.35-0.48], cardiac death (RR 0.44, 95% CI: 0.35-0.55) and major adverse cardiac events (MACE) (RR 0.64, 95% CI: 0.43-0.97). But there were no differences in myocardial infarction (MI) and stroke. The results of the propensity-matched subgroup were somewhat consistent with those of the main analysis (all-cause death: RR 0.57, 95% CI: 0.26-0.89; MI: RR 0.54, 95% CI: 0.32-0.77; and MACE: RR 0.76, 95% CI: 0.33-1.18). In IRA subgroup, PCI reduced risks of mortality (all-cause death: RR 0.41, 95% CI: 0.34-0.49; cardiac death: RR 0.44, 95% CI: 0.35-0.56) and MACE (RR 0.71, 95% CI: 0.46-1.10). But no difference was observed in MI.

Conclusions

PCI was associated with improved survival and reduced MACE relative to OMT.

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.

Predictors of poor clinical outcomes after successful chronic total occlusion intervention with drug-eluting stents

BACKGROUND

The aim of this study was to identify the prognostic predictors for the worse clinical outcomes after a successful chronic total occlusion (CTO) intervention with drug-eluting stents.

PATIENTS AND RESULTS

A total of 2334 patients in the multicenter Korean CTO registry who underwent a successful CTO intervention with drug-eluting stents (first generation, 1367, new generation, 967) were enrolled. The primary endpoint was the composite of cardiac death, myocardial infarction, and stent thrombosis.The cumulative incidence of the primary endpoint was 2.5% (median follow-up duration: 22 months). In multivariate analysis, age above 65 years [hazard ratio (HR)=1.769, 95% confidence interval (CI)=1.025-3.052, P=0.041], heart failure (HR=4.242, 95% CI=2.335-7.705, P<0.001), and diabetes (HR=1.773, 95% CI=1.043-3.012, P=0.034) were the significant predictors. The cumulative incidence of the primary endpoint was significantly higher in patients with three risk factors (19.1%) than in those with one (2.2%) or two (3.0%) risk factors (P=0.001). The cumulative target-vessel revascularization rate was 8.4%, with the significant predictors being a diffuse long lesion (HR=1.626, 95% CI=1.129-2.340, P=0.009) and at least three implanted stents (HR=1.964, 95% CI=1.301-2.965, P=0.001).

CONCLUSION

Clinical parameters such as age, diabetes, and heart failure were independent predictors of the composite of cardiac death, myocardial infarction, and stent thrombosis, whereas angiographic or procedural parameters such as lesion length and number of implanted stents were predictors of target-vessel revascularization. Clinical outcomes after CTO intervention were worse in patients with multiple risk factors.

Subadventitial techniques for chronic total occlusion percutaneous coronary intervention: The concept of "vessel architecture"

Despite improvements in guidewire technologies, the traditional antegrade wire escalation approach to chronic total occlusion (CTO) recanalization is successful in only 60-80% of selected cases. In particular, long, calcified, and tortuous occlusions are less successfully approached with a true-to-true lumen approach. Frequently, the guidewire tracks into the subadventitial space, with no guarantee of distal re-entry into the true lumen. The ability to manage the subadventitial space has been a key step in the tremendous improvement in success rates of contemporary CTO percutaneous coronary intervention (PCI), whether operating antegradely or retrogradely. A modern approach to CTO PCI involves understanding the concept of "vessel architecture," which is based on the distinction between coronary structures (occlusive plaque, comprising the disrupted intima and media, and the outer adventitia) and extravascular space. The vessel architecture represents a safe work environment for guidewire and device manipulation. This review provides an anatomy-based description of the concept of vessel architecture, along with a historical perspective of subadventitial techniques for CTO PCI, and outcome data of CTO PCI utilizing the subadventitial space. © 2017 Wiley Periodicals, Inc.

Hybrid Approach to Percutaneous Coronary Intervention to Treat Chronic Total Occlusions

The hybrid approach is a systematic algorithm-led percutaneous coronary intervention strategy based on the identification of key anatomical features on coronary angiography to treat chronic total occlusions. The aims of this approach are to provide a standardised tool for physician training and programme development, avoiding futile strategies to improve safety, procedural success and reduce the contrast and radiation required to complete the case.

CT Angiography for Revascularization of CTO: Crossing the Borders of Diagnosis and Treatment

Coronary computed tomography angiography (CTA) is increasingly used to diagnose and rule out coronary artery disease. Beyond stenosis detection, the ability of CTA to visualize and characterize coronary atherosclerotic plaque, as well as to obtain 3-dimensional coronary vessel trajectories, has generated considerable interest in the context of pre-procedural planning for revascularization of chronic total occlusions (CTOs). Coronary CTA can characterize features that influence the success rate of percutaneous coronary intervention (PCI) for CTOs such as the extent of calcification, vessel tortuosity, stump morphology, presence of multiple occlusions, and lesion length. Single features and combined scoring systems based on CTA may be used to grade the level of difficulty of the CTOs before PCI and have been shown to predict procedural success rates in several trials. In addition, the procedure itself may be facilitated by real-time integration of 3-dimensional CTA data and fluoroscopic images in the catheterization laboratory. Finally, the ability of coronary CTA to assess anatomy, perfusion, and viability in 1 single examination makes it a potential "one stop shop" that predicts not only the likelihood of successful PCI but also the clinical benefit of CTO revascularization. Further research is clearly needed, but many experienced sites have already integrated coronary CTA into the routine planning and guiding of CTO procedures.

Percutaneous Coronary Revascularization for Chronic Total Occlusions: A Novel Predictive Score of Technical Failure Using Advanced Technologies

OBJECTIVES

The aims of this study were to describe the 10-year experience of a single operator dedicated to chronic total occlusion (CTO) and to establish a model for predicting technical failure.

BACKGROUND

During the last decade, the interest in percutaneous coronary interventions (PCIs) of chronic total occlusions (CTOs) has increased, allowing the improvement of success rate.

METHODS

One thousand nineteen patients with CTO underwent 1,073 CTO procedures performed by a single CTO-dedicated operator. The study population was subdivided into 2 groups by time period: period 1 (January 2005 to December 2009, n = 378) and period 2 (January 2010 to December 2014, n = 641). Observations were randomly assigned to a derivation set and a validation set (in a 2:1 ratio). A prediction score was established by assigning points for each independent predictor of technical failure in the derivation set according to the beta coefficient and summing all points accrued.

RESULTS

Lesions attempted in period 2 were more complex in comparison with those in period 1. Compared with period 1, both technical and clinical success rates significantly improved (from 87.8% to 94.4% [p = 0.001] and from 77.6% to 89.9% [p < 0.001], respectively). A prediction score for technical failure including age ≥75 years (1 point), ostial location (1 point), and collateral filling Rentrop grade <2 (2 points) was established, stratifying procedures into 4 difficulty groups: easy (0), intermediate (1), difficult (2), and very difficult (3 or 4), with decreasing technical success rates. In derivation and validation sets, areas under the curve were comparable (0.728 and 0.772, respectively).

CONCLUSIONS

With growing expertise, the success rate has increased despite increasing complexity of attempted lesions. The established model predicted the probability of technical failure and thus might be applied to grading the difficulty of CTO procedures.

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.

Update on Coronary Chronic Total Occlusion Percutaneous Coronary Intervention

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has significantly evolved during recent years. High success rates are being achieved by experienced centers and operators, but not at less-experienced centers. Use of CTO crossing algorithms can help improve the success and efficiency of these potentially lengthy procedures. There is a paucity of clinical trial data examining clinical outcomes of CTO PCI, which is critical for further adoption and refinement of the procedure. We provide a detailed overview of the clinical evidence and current available crossing strategies, with emphasis on recent developments and techniques.

Chronic total improvement in ventricular function and survival

Coronary chronic total occlusions (CTOs) represent a frequent lesions' subset observed in everyday catheterization laboratory practice. Previously considered to be an indication for surgical myocardial revascularization, the interest of interventional community in CTOs has exponentially grown during the last decade, particularly thanks to an important development in dedicated equipment and techniques, and has led to the achievement of high rates of success and low rates of complications by expert operators. In absence of available data from randomized trials, several observational studies have shown the benefits of CTO percutaneous coronary intervention (PCI) in insuring better cardiovascular outcome, particularly by improving ventricular function and reducing cardiac mortality.

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization.