Retrograde Chronic Total Occlusion Percutaneous Coronary Intervention via Saphenous Vein Graft

Complex Retrograde Chronic Occlusion Percutaneous Coronary Intervention via a Gastroepiploic Artery Graft

Surgical bypass grafts are commonly used retrograde conduits to facilitate chronic total occlusion (CTO) percutaneous coronary intervention (PCI). While extensive experience exists using saphenous vein grafts as retrograde conduits in CTO PCI, information on the utilization of arterial grafts is more limited. In particular, the gastroepiploic artery (GEA) is a very uncommonly used arterial graft in contemporary bypass surgery and its role for retrograde CTO recanalization has received little study. We describe a case of right coronary artery CTO that was recanalized using the retrograde approach via a GEA graft to the posterior descending artery and highlight the specific challenges of this approach.

Retrograde CTO-PCI Using an Internal Thoracic Bypass Graft Segment in a Patient with Acute Inferior ST-Elevation Myocardial Infarction and Cardiogenic Shock

Background

Percutaneous coronary intervention (PCI) of the “culprit” artery is the recommended mechanical reperfusion strategy in the setting of ST-segment elevation myocardial infarction (STEMI). As PCI of bypass grafts may be associated with higher risks and lower procedural success rates, in patients with a history of previous coronary artery surgery, PCI directed at revascularization of the native vessels should be considered, but this may be difficult in the setting of a chronically occluded artery.

Case Presentation

A patient with a history of multivessel coronary artery disease and a chronic total occlusion (CTO) of the right coronary artery (RCA) requiring arterial bypass surgery, presented with an acute inferior STEMI and cardiogenic shock. It was felt that shock was caused by the acute thrombotic occlusion of a right internal thoracic artery (RITA) bypass graft that had been sequentially anastomosed to the left circumflex (LCx) and right coronary arteries. Despite initiation of extracorporeal membrane oxygenation (ECMO), the patient remained in refractory shock and acute revascularization of the right coronary artery was performed through the RITA bypass segment using antegrade access to the graft through the LCx and then a retrograde approach to open a CTO of the RCA. After successful revascularization, the patient was successfully weaned from ECMO. Over 12 months of follow-up, the patient did well and was documented to have improved left ventricular systolic function.

Conclusion

This report is the first to document the successful use of a retrograde approach through an arterial graft segment to revascularize a chronic total occlusion in the setting of acute STEMI and cardiogenic shock.

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.

Contemporary coronary artery bypass graft surgery and subsequent percutaneous revascularization

Patients who have undergone coronary artery bypass graft (CABG) surgery are susceptible to bypass graft failure and progression of native coronary artery disease. Although the saphenous vein graft (SVG) was traditionally the most-used conduit, arterial grafts (including the left and right internal thoracic arteries and the radial artery) have improved patency rates. However, the need for secondary revascularization remains common, and percutaneous coronary intervention (PCI) has become the most common modality of secondary revascularization after CABG surgery. Procedural characteristics and clinical outcomes differ considerably from those associated with PCI in patients without previous CABG surgery, owing to altered coronary anatomy and differences in conduit pathophysiology. In particular, SVG PCI carries an increased risk of complications, and operators are shifting their focus towards embolic protection strategies and complex native-vessel interventions, increasingly using SVGs as conduits to facilitate native-vessel PCI rather than pursuing SVG PCI. In this Review, we discuss the differences in conduit pathophysiology, changes in CABG surgery techniques, and the latest evidence in terms of PCI in patients with previous CABG surgery, with a particular emphasis on safety and long-term efficacy. We explore the subject of contemporary CABG surgery and subsequent percutaneous revascularization in this complex patient population.

Lesion characteristics and procedural complications of chronic total occlusion percutaneous coronary intervention in patients with prior bypass surgery: A meta-analysis

Coronary artery bypass graft (CABG) accelerates the prevalence of native coronary chronic total occlusion (CTO), and this kind of CTO shows extensive challenging and complex atherosclerotic pathology. As a result, the procedural success rate of percutaneous coronary intervention (PCI) is inferior to another kind of lesions. The present meta-analysis aims to compare the lesion characteristics and procedural complications of CTO-PCI in patients with or without prior CABG. A total of 8 studies, comprising of 13439 patients, published from inception to August 2021 were included in this meta-analysis. Results were pooled using random effects model and are presented as odds ratio (OR) with 95% confidence intervals (95% CIs). From the 13439 patients enrolled, 3349 (24.9%) patients had previous CABG and 10090 (75.1%) formed the control group in our analysis. For the clinical characteristic, compared to the non-CABG patients, prior CABG patients were older (OR, 3.98; 95% CI, 3.19-4.78; p < .001; I2  = 72%), had more male (OR, 1.30; 95% CI, 1.14-1.49; p < .001; I2  = 6%), diabetes mellitus (OR, 1.54; 95% CI, 1.36-1.73; p < .001; I2  = 37%), dyslipidemia (OR, 1.89; 95% CI, 1.33-2.69; p < .001; I2  = 81%), hypertension (OR, 1.88; 95% CI, 1.46-2.41; p < .001; I2  = 71%), previous myocardial infarction (OR, 1.94; 95% CI, 1.48-2.56; p < .001; I2  = 85%), and previous PCI (OR, 1.74; 95% CI, 1.52-1.98; p < .001; I2  = 22%). Non-CABG patents had more current smoker (OR, .45; 95% CI, 0.27-0.74; p < .001; I2  = 91%). BMI (OR, -0.01; 95% CI, -0.07-0.06; p = .85; I2  = 36%) were similar in both groups. For lesions location, the right coronary artery (RCA) was predominant target vessel in both groups (50.5% vs 48.7%; p＝.49), although, the left circumflex (LCX) was more frequently CTO in the prior CABG group (27.3% vs 18.9%; p＜.01), while left anterior descending artery (LAD) in non-CABG ones (16.0% vs 29.1%; p＜0.01). For lesions characteristics, prior CABG patients had more blunt stump (OR, 1.71; 95% CI, 1.46-2.00; p < .001; I2  = 40%), proximal cap ambiguity (OR, 1.45; 95% CI, 1.28-1.64; p < .001; I2  = 0.0%), severe calcifications (OR, 2.91; 95% CI, 2.19-3.86; p < .001; I2  = 83%), more bending (OR, 3.07; 95% CI, 2.61-3.62; p < .001; I2  = 0%), lesion length > 20 mm (OR, 1.59; 95% CI, 1.10-2.29; p = .01; I2  = 83%), inadequate distal landing zone (OR, 1.95; 95% CI, 1.75-2.18; p＜.001; I2  = 0.0%), distal cap at bifurcation (OR, 1.65; 95% CI, 1.46-1.88; p < .001; I2  = 0.0%), and higher J-CTO score (SMD, 0.52; 95% CI, 0.42-0.63; p < .001; I2  = 65%). But side branch at proximal entry (OR, 0.88; 95% CI, 0.72-1.07; p = .21; I2  = 45%), in-stent CTO (OR, 0.99; 95% CI, 0.86-1.14; p = .88; I2  = 0.0%), lack of interventional collaterals (OR, 0.80; 95% CI, 0.55-1.15; p = .23; I2  = 78%), and previously failed attempt (OR, 0.73; 95% CI, 0.48-1.11; p = .14; I2  = 89%) were similar in both groups. For complication, prior CABG patients had more perforation with need for intervention (OR, 1.91; 95% CI, 1.36-2.69; p < 0.001; I2  = 34%), contrast-induced nephropathy (OR, 3.40; 95% CI, 1.31-8.78; p = .01; I2  = 0.0%). Non-CABG patents had more tamponade (OR, 0.25; 95% CI, 0.09-0.72; p = .01; I2  = 0.0%), and the major bleeding complication (OR, 1.18; 95% CI, 0.57-2.44; p = .65; I2  = 0%) were no significant difference in both groups. In conclusion, Patients with prior CABG undergoing CTO-PCI have more complex lesion characteristics, though procedural complication rates were comparable.

Saphenous Vein Graft Failure: From Pathophysiology to Prevention and Treatment Strategies

Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG). Despite advances in surgical techniques and pharmacotherapy, SVG failure rates remain high, often leading to repeat coronary revascularization. The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure, whereas the effect of the off-pump technique on SVG patency remains unclear. Use of buffered storage solutions, intraoperative graft flow measurement, careful selection of the target vessels, and physiological assessment of the native coronary circulation before CABG may also reduce the incidence of SVG failure. Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG. Dual antiplatelet therapy is recommended for off-pump CABG and in patients with a recent acute coronary syndrome. Intermediate (30%-60%) SVG stenoses often progress rapidly. Stenting of intermediate SVG stenoses failed to improve outcomes; hence, treatment focuses on strict control of coronary artery disease risk factors. Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG. SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up. Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI. Embolic protection devices reduce no-reflow and should be used when feasible. PCI of the corresponding native coronary artery is associated with better short- and long-term outcomes and is preferred over SVG PCI, if technically feasible.

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.

Vein Graft Coil Embolization and Successful Retrieval With a Micro-Snare

Following successful retrograde CTO PCI via a degenerating saphenous vein graft, persistent TIMI II flow was noted in the graft. Given increased risk of target vessel failure in the presence of significant competitive flow from a saphenous vein graft, the SVG underwent coil embolization with two 4 mm × 6 cm detachable coils. Follow up angiography with forceful contrast injection resulted in embolization of the coils into the patient's two remaining patent grafts. The coils were then retrieved using a micro-snare. The patient tolerated the procedure with no compromise of flow into the remaining grafts and resolution of angina following CTO PCI.

The Canadian Contribution to Science, Techniques, Technology, and Education in Chronic Total Occlusion Percutaneous Coronary Intervention

Chronic total occlusions are considered the most complex coronary lesions in interventional cardiology. This article reviews the Canadian clinical and academic contributions to this field, including innovative procedural techniques, teaching and proctoring, clinical research, and the development of novel tools and therapies.

Impact of adherence to the hybrid algorithm for initial crossing strategy selection in chronic total occlusion percutaneous coronary intervention

INTRODUCTION AND OBJECTIVES

The hybrid algorithm was designed to assist with initial and subsequent crossing strategy selection in chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). However, the success of the initially selected strategy has received limited study.

METHODS

We examined the impact of adherence to the hybrid algorithm recommendation for initial CTO crossing technique selection in 4178 CTO PCIs from a large multicenter registry.

RESULTS

The initial crossing strategy was concordant with the hybrid algorithm recommendation in 1833 interventions (44%). Patients in the concordant group had a similar age to those in the discordant group but a lower mean J-CTO score (2.0 ± 1.4 vs 2.8 ± 1.1; P < .01). The concordant group showed higher technical success with the first crossing strategy (68% vs 48%; P < .01) and higher overall technical success (88% vs 83%; P < .01) with no difference in the incidence of in-hospital major adverse events (1.8% vs 2.3%; P = .26). In multivariable analysis, after adjustment for age, prior myocardial infarction, prior PCI, prior coronary artery bypass grafting, J-CTO score, and scheduled CTO PCI, nonadherence to the hybrid algorithm was independently associated with lower technical success of the initial crossing strategy (odds ratio, 0.55; 95% confidence interval, 0.48-0.64; P < .01).

CONCLUSIONS

Adherence to the hybrid algorithm for initial crossing strategy selection is associated with higher CTO PCI success but similar in-hospital major adverse cardiac events.

Latest developments in chronic total occlusion percutaneous coronary intervention

INTRODUCTION

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.

AREAS COVERED

We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.

EXPERT OPINION

After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.