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Liu SC, Lee CL, Cheng JF, Chiang JY, Tsai CT, Chang CJ, Lin CP, Huang CH, Liou JT, Tsai CT, Wang YC, Hwang JJ. Role of calcification in J-CTO score: a viewpoint of intraplaque guidewire tracking techniques. Ann Med 2024; 56:2396076. [PMID: 39193705 PMCID: PMC11360632 DOI: 10.1080/07853890.2024.2396076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND As the burden and distribution of calcification within chronic total occlusion (CTO) lesions can be diverse, its effect on CTO recanalization using multiple devices and techniques is debatable. This study investigated the role of calcification in wiring-based intraplaque tracking techniques for CTO recanalization. METHODS A modified J-CTO score without counting calcification was used to analyze the procedures of 458 consecutive patients who underwent CTO interventions. Failed guidewire crossing and intraplaque tracking were considered procedural failures. Recanalization time details were analyzed for successful procedures. RESULTS In patients with calcified CTO, the rate of procedural success only significantly declined to be lower than that of noncalcified CTO when the modified J-CTO score was ≥3 (77% vs. 94%, p = 0.008). In 422 patients with successful procedures, the presence of calcification was irrelevant to guidewire crossing time, but was accompanied with longer time from guidewire cross to final angiogram when the modified J-CTO score was 1-2 (53 ± 35 vs. 35 ± 17 [noncalcified] min, p < 0.001). Multivariate analyses showed that calcification was independently associated with procedural failure (odds ratio [OR] = 5.1, 95% confidence interval [CI] = 1.4-18.3) in lesions with modified J-CTO ≥3, and prolonged angioplasty/stenting procedures >60 min (OR = 4.8, 95% CI = 2.2-10.2) in successfully recanalized lesions with modified J-CTO score 1-2. CONCLUSIONS Using intraplaque guidewire tracking, calcification was unfavorable for very difficult CTO lesions, and caused prolongation of angioplasty time for lesions with moderate complexity. This suggested that the role of calcification in the J-CTO score could be altered when different recanalization techniques were applied for CTO interventions.
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Affiliation(s)
- Shih-Chi Liu
- Cardiovascular Division, Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Chien-Lin Lee
- Cardiovascular Division, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Jen-Fang Cheng
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiunn-Yang Chiang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Ting Tsai
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chi-Jen Chang
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Pin Lin
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Hung Huang
- Cardiovascular Division, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Jun-Ting Liou
- Cardiovascular Division, Department of Internal Medicine, China Medical University Hsinchu Hospital, Zhubei City, Taiwan
| | - Chia-Ti Tsai
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chih Wang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Masoomi R, Moscardelli S, Hirai T, Azzalini L. Antegrade techniques for chronic total occlusion percutaneous coronary intervention. Prog Cardiovasc Dis 2024:S0033-0620(24)00098-7. [PMID: 39032669 DOI: 10.1016/j.pcad.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 07/07/2024] [Indexed: 07/23/2024]
Abstract
Antegrade techniques are the foundation of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Antegrade wiring with the intent to achieve an intraplaque guidewire tracking is not always feasible, and crossing into the extraplaque space with subsequent reentry (antegrade dissection and reentry), might be needed, particularly in more complex occlusions. The present article reviews in detail the antegrade approaches to CTO PCI, focusing on equipment, techniques, and overcoming challenges.
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Affiliation(s)
- Reza Masoomi
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Silvia Moscardelli
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA; University of Milan, Milan, Italy
| | - Taishi Hirai
- Division of Cardiology, Department of Medicine, University of Missouri, Columbia, MO, USA
| | - Lorenzo Azzalini
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA.
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Frederiks P, Castaldi G, McCutcheon K, Bennett J. Platinum chromium everolimus-eluting stents for the treatment of (complex) coronary artery disease; from SYNERGY™ to the MEGATRON™. Expert Rev Med Devices 2024; 21:601-611. [PMID: 38720513 DOI: 10.1080/17434440.2024.2353722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION The introduction of drug-eluting coronary stents (DES) into clinical practice in 2002 represented a major milestone in the treatment of obstructive coronary artery disease. Over the years, significant advances in polymer coating and in antiproliferative agent technology have further improved the safety and clinical performance of newer-generation DES. AREAS COVERED Development of platinum chromium (PtCr) alloys with high radial strength and high radiopacity have enabled the design of new, thin-strut, flexible, and highly trackable stent platforms, while simultaneously improving stent visibility. These advances have facilitated complex percutaneous treatment of a diverse population of patients in clinical practice. This review will provide an overview of the evolution in PtCr everolimus-eluting stents from PROMUS Element™ to SYNERGY™ to the recently introduced SYNERGY MEGATRON™. The clinical data will be summarized and put into perspective, especially focusing on the role of the SYNERGY™ and MEGATRON™ platforms in the treatment of complex coronary artery disease and high-risk patients. EXPERT OPINION The SYNERGY™ stent demonstrates favorable clinical efficacy and safety outcome data, and whilst the clinical data on MEGATRON™ are sparse, early experience is promising. The specific overexpansion capabilities, visibility, and radial strength of the MEGATRON™ are attractive features for complex coronary interventions.
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Affiliation(s)
- Pascal Frederiks
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Gianluca Castaldi
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Keir McCutcheon
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Cardiology, Lady Pohamba Private Hospital, Windhoek, Namibia
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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4
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Gilpin TR, Maznyczka A, Anantharam B, Dana A. Procedural Results and Long-term Outcome of Chronic Total Occlusion Percutaneous Coronary Intervention in a UK Non-surgical Centre. Interv Cardiol 2024; 19:e05. [PMID: 38808283 PMCID: PMC11131147 DOI: 10.15420/icr.2023.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/08/2023] [Indexed: 05/30/2024] Open
Abstract
Background Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has evolved a great deal over recent years, with increased procedural success and lower complication rates being reported. This study aims to evaluate the feasibility, safety and success of a dedicated CTO programme in a large UK PCI centre without on-site cardiothoracic surgery facilities. Methods Clinical and procedural data were retrospectively collected for consecutive unselected patients undergoing CTO PCI between 2015 and 2019 from the local database and regional electronic patient records. In-hospital outcomes and long-term major adverse cardiovascular events (all-cause mortality, MI, stroke and target vessel revascularisation) were recorded. Results A total of 170 patients underwent 191 CTO procedures during the study period. The mean age was 63 ± 10 years and 80.6% of patients were male (n=137). The clinical indications were: stable chronic coronary syndromes in 88.5% (n=169) of patients; staged procedures in the context of acute coronary syndromes in 1.6% (n=3); and presentation with acute coronary syndrome in 9.9% (n=19). The procedural success rate was 50.0% (n=25) for general interventional cardiologists and 90.1% (n=127) for dedicated CTO operators. In-hospital major adverse cardiovascular events occurred once (0.5%) and interhospital transfer for emergency salvage cardiac surgery was not required. Long-term follow-up data at a median duration of 3.8 years revealed 4 (2.4%) cardiac deaths, 14 (8.3%) spontaneous MI events and 10 (5.9%) target vessel revascularisations. Conclusion These data suggest CTO PCI using contemporary techniques is both safe and effective when undertaken in a high-volume non-surgical centre by experienced operators.
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Affiliation(s)
- Thomas R Gilpin
- Faculty of Medicine, University of SouthamptonSouthampton, UK
- Portsmouth Hospitals University NHS Trust, Queen Alexandra HospitalPortsmouth, UK
| | - Annette Maznyczka
- Portsmouth Hospitals University NHS Trust, Queen Alexandra HospitalPortsmouth, UK
| | - Brijesh Anantharam
- Portsmouth Hospitals University NHS Trust, Queen Alexandra HospitalPortsmouth, UK
| | - Ali Dana
- Portsmouth Hospitals University NHS Trust, Queen Alexandra HospitalPortsmouth, UK
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Zyśk A, Wolny R, Kruk M, Kwieciński J, Dębski A, Barbero U, Kępka C, Demkow M, Witkowski A, Opolski MP. Computed Tomography Angiography-Derived Scores for Prediction of Chronic Total Occlusion Percutaneous Coronary Intervention Using the Hybrid Algorithm. J Cardiovasc Dev Dis 2023; 11:3. [PMID: 38248873 PMCID: PMC10817054 DOI: 10.3390/jcdd11010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Whereas coronary computed tomography angiography (CCTA) exceeds invasive angiography for predicting the procedural outcome of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), CCTA-derived scores have never been validated in the hybrid CTO PCI population. In this single-center, retrospective, observational study, we included 108 consecutive patients with 110 CTO lesions and preprocedural CCTA who underwent hybrid CTO PCI to assess the diagnostic accuracy of CCTA-derived scoring systems. Successful guidewire crossing within 30 min was set as the primary endpoint. The secondary endpoints were final procedural success and the need for using any non-antegrade wiring (AW) strategy within the hybrid algorithm. Time-efficient guidewire crossing and final procedural success were achieved in 53.6% and 89.1% of lesions, respectively, while in 36.4% of the procedures, any non-AW strategy was applied. The median J-CTO score was 1 (interquartile range (IQR): 0, 2), while the CT-RECTOR, KCCT, J-CTOCCTA, and RECHARGECCTA scores were 2 (IQR: 1, 3), 3 (IQR: 2, 5), 1 (IQR: 0, 3), and 2 (IQR: 1, 3), respectively. All scores were significantly higher in the lesions with failed versus successful time-efficient guidewire crossing. Although all of the CCTA-derived scores had numerically higher predictive values than the angiographic J-CTO score, no significant differences were noted between the scores in any of the analyzed study endpoints. High sensitivity of the CT-RECTOR and RECHARGECCTA scores (both 89.8%) for predicting successful guidewire crossing within 30 min, and high sensitivity (90.8%) of the KCCT score for predicting final procedural success, were noted. CCTA-derived scoring systems are accurate, noninvasive tools for the prediction of the procedural outcome of hybrid CTO PCI, and may aid in identifying the need for use of the hybrid algorithm.
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Affiliation(s)
- Antoni Zyśk
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, 04-682 Warsaw, Poland (M.P.O.)
| | - Rafał Wolny
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, 04-682 Warsaw, Poland (M.P.O.)
| | - Mariusz Kruk
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, 04-682 Warsaw, Poland
| | - Jacek Kwieciński
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, 04-682 Warsaw, Poland (M.P.O.)
| | - Artur Dębski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, 04-682 Warsaw, Poland (M.P.O.)
| | - Umberto Barbero
- Department of Cardiology, Santissima Annunziata Hospital, 12038 Savigliano, Italy
| | - Cezary Kępka
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, 04-682 Warsaw, Poland
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, 04-682 Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, 04-682 Warsaw, Poland (M.P.O.)
| | - Maksymilian P. Opolski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, 04-682 Warsaw, Poland (M.P.O.)
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Xenogiannis I, Pavlidis AN, Kaier TE, Rigopoulos AG, Karamasis GV, Triantafyllis AS, Vardas P, Brilakis ES, Kalogeropoulos AS. The role of intravascular imaging in chronic total occlusion percutaneous coronary intervention. Front Cardiovasc Med 2023; 10:1199067. [PMID: 37767372 PMCID: PMC10520251 DOI: 10.3389/fcvm.2023.1199067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Chronic total occlusions (CTOs) represent the most complex subset of coronary artery disease and therefore careful planning of CTO percutaneous coronary recanalization (PCI) strategy is of paramount importance aiming to achieve procedural success, and improve patient's safety and post CTO PCI outcomes. Intravascular imaging has an essential role in facilitating CTO PCΙ. First, intravascular ultrasound (IVUS), due to its higher penetration depth compared to optical coherence tomography (OCT), and the additional capacity of real-time imaging without need for contrast injection is considered the preferred imaging modality for CTO PCI. Secondly, IVUS can be used to resolve proximal cap ambiguity, facilitate wire re-entry when dissection and re-entry strategies are applied and most importantly to guide stent deployment and optimization post implantation. The role of OCT during CTO PCI is currently limited to stent sizing and optimization, however, due to its high spatial resolution, OCT is ideal for detecting stent edge dissections and strut malapposition. In this review, we describe the use of intravascular imaging for lesion crossing, plaque characterization and wire tracking, extra- or intra-plaque, and stent sizing and optimization during CTO PCI and summarize the findings of the major studies in this field.
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Affiliation(s)
- Iosif Xenogiannis
- Department of Cardiology, Mitera General Hospital, Hygeia HealthCare Group, Athens, Greece
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Antonis N. Pavlidis
- Department of Cardiology, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Thomas E. Kaier
- Department of Cardiology, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Angelos G. Rigopoulos
- Department of Cardiology, Mitera General Hospital, Hygeia HealthCare Group, Athens, Greece
| | - Grigoris V. Karamasis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | | | - Panos Vardas
- Department of Cardiology, Mitera General Hospital, Hygeia HealthCare Group, Athens, Greece
| | - Emmanouil S. Brilakis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, United States
| | - Andreas S. Kalogeropoulos
- Department of Cardiology, Mitera General Hospital, Hygeia HealthCare Group, Athens, Greece
- Department of Cardiology, St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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7
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Lefèvre T, Pan M, Stankovic G, Ojeda S, Boudou N, Brilakis ES, Sianos G, Vadalà G, Galassi AR, Garbo R, Louvard Y, Gutiérrez-Chico JL, di Mario C, Hildick-Smith D, Mashayekhi K, Werner GS. CTO and Bifurcation Lesions: An Expert Consensus From the European Bifurcation Club and EuroCTO Club. JACC Cardiovasc Interv 2023; 16:2065-2082. [PMID: 37704294 DOI: 10.1016/j.jcin.2023.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/14/2023] [Accepted: 06/13/2023] [Indexed: 09/15/2023]
Abstract
Knowledge in the field of bifurcation lesions and chronic total occlusions (CTOs) has progressively improved over the past 20 years. Therefore, the European Bifurcation Club and the EuroCTO Club have decided to write a joint consensus statement to share general knowledge and practical approaches in this complex field. When percutaneously treating CTOs, bifurcation lesions with relevant side branches (SBs) are found in approximately one-third of cases (35% at the proximal cap, 38% at the distal cap, and 27% within the CTO body). Occlusion of a relevant SB is not rare and has been shown to be associated with procedural complications and adverse outcomes. Simple bifurcation rules are very useful to prevent SB occlusion, and provisional SB stenting is the recommended approach in the majority of cases: protect the SB as soon as possible by wiring it, respect the fractal anatomy of the bifurcation by using the 3-diameter rule, and avoid using dissection and re-entry techniques. A systematic 2-stent approach can be used if needed or sometimes to connect both branches of the bifurcation. The retrograde approach can be very useful to save a relevant SB, especially in the case of a bifurcation at the distal cap or within the CTO body. Intravascular ultrasound is also a very important tool to address the difficulties with bifurcations at the proximal or distal cap and sometimes also within the CTO segment. Double-lumen microcatheters and angulated microcatheters are crucial tools to resolve access difficulties to the SB or the main branch.
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Affiliation(s)
- Thierry Lefèvre
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France.
| | - Manuel Pan
- Reina Sofía Hospital, University of Cordoba, Instituto Maimónides de Investigación Biomédica de Córdoba, Cordoba, Spain
| | - Goran Stankovic
- Department of Cardiology, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | - Soledad Ojeda
- Reina Sofía Hospital, University of Cordoba, Instituto Maimónides de Investigación Biomédica de Córdoba, Cordoba, Spain
| | | | - Emmanouil S Brilakis
- Allina Health Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | | | - Giuseppe Vadalà
- Division of Cardiology, University Hospital "P. Giaccone," Palermo, Italy
| | - Afredo R Galassi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Roberto Garbo
- Interventional Cardiology Department, Maria Pia Hospital, GVM Care & Research, Turin, Italy
| | - Yves Louvard
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | | | - Carlo di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Kambis Mashayekhi
- Department of Interventional Cardiology, Cardiology and Angiology II, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Gerald S Werner
- Heart Center Lahr, Lahr, Germany; Medizinische Klinik I, Klinikum Darmstadt, Darmstadt, Germany
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Kwiecinski J, Oleksiak A, Kruk M, Zysk A, Debski A, Knaapen P, Schumacher SP, Barbero U, Witkowski A, Kepka C, Opolski MP. Computed tomography perfusion and angiography in patients with chronic total occlusion undergoing percutaneous coronary intervention. Atherosclerosis 2023; 381:117174. [PMID: 37400307 DOI: 10.1016/j.atherosclerosis.2023.06.080] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND AND AIMS Myocardial perfusion imaging (MPI) and anatomical imaging with coronary computed tomography angiography (CCTA) can play an important role in the preprocedural planning of a chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to establish the feasibility of a novel dynamic computed tomography perfusion (CTP) analysis for the assessment of myocardial perfusion before and after a successful recanalization of CTO in patients undergoing CCTA as part of a standard preprocedural workup. METHODS In a prospective observational study symptomatic patients underwent dynamic CTP on a dual-source CT scanner both before and 3 months after successful CTO PCI. RESULTS Twenty-seven patients completed the study (63 ± 8 years old, 78% male). Following successful CTO PCI, there was a significant reduction in the ischemic burden (5 [5-7] versus 1 [0-2] segments, p < 0.001), and improvement in myocardial blood flow (85.3 [71.7-94.1] versus 134.6 [123.8-156.9] mL/min, p < 0.001) resulting in an increase in the relative flow reserve (0.49 [0.41-0.57] versus 0.88 [0.74-0.95], p < 0.001). CONCLUSIONS CTP emerges as a robust and safe method for MPI in CTO patients. The single imaging session assessment of both coronary anatomy and perfusion with CT lends itself to precise disease phenotyping in the challenging population of CTO patients.
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Affiliation(s)
- Jacek Kwiecinski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Anna Oleksiak
- Department of Intensive Cardiac Therapy, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Kruk
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - Antoni Zysk
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Artur Debski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Stefan P Schumacher
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Umberto Barbero
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland; Department of Cardiology, Santissima Annunziata Hospital, Savigliano, Italy
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Cezary Kepka
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - Maksymilian P Opolski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland.
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9
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Khan SA, Alsanjari O, Keulards DCJ, Vlaar PJ, Zhang J, Konstantinou K, Fawaz S, Simpson R, Clesham G, Kelly PA, Tang KH, Cook CM, Cockburn J, Pijls NHJ, Hildick-Smith D, Teeuwen K, Keeble TR, Karamasis GV, Davies JR. Changes in absolute flow, myocardial resistance and FFR after chronic total occlusion percutaneous coronary intervention. EUROINTERVENTION 2023; 19:e123-e133. [PMID: 36722201 PMCID: PMC10242660 DOI: 10.4244/eij-d-22-00694] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/07/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Randomised studies of percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) have shown inconsistent outcomes, suggesting incomplete understanding of this cohort and their coronary physiology. To address this shortcoming, we designed a prospective observational study to measure the recovery of absolute coronary blood flow following successful CTO PCI Aims: We sought to identify patient and procedural characteristics associated with a favourable physiological outcome after CTO PCI. METHODS Consecutive patients with a CTO subtending viable myocardium underwent PCI utilising contemporary techniques and the hybrid algorithm. Immediately after PCI, and at 3-month follow-up, physiological measurements were performed utilising continuous thermodilution. RESULTS A total of 81 patients were included with a mean age of 63.6±8.9 years, and 66 (81.5%) were male. Physiological measurements of absolute coronary blood flow in the CTO vessel increased by 30% (p<0.001) and microvascular resistance reduced by 16% (p<0.001) from immediately post-CTO PCI to follow-up assessment. Fractional flow reserve increased by 0.02 (p=0.015) in the same period. Prior coronary artery bypass graft (CABG) and a higher estimated glomerular filtration rate (eGFR) were associated with a larger change in absolute flow. An extraplaque strategy was associated with a smaller change in absolute flow. CONCLUSIONS Post-CTO PCI, there is a continued augmentation in absolute coronary blood flow and reduction in microvascular resistance from baseline to follow-up at 3 months. Prior CABG and a higher baseline eGFR were predictors of a larger change in absolute coronary flow, whilst an extraplaque final wire path strategy predicted a smaller change. Lastly, the patient characteristics and comorbidities had a larger influence than procedural factors on the observed change in absolute flow.
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Affiliation(s)
- Sarosh A Khan
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Osama Alsanjari
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | | | | | | | - Klio Konstantinou
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Samer Fawaz
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Rupert Simpson
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Gerald Clesham
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | | | | | - Christopher M Cook
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | | | | | | | | | - Thomas R Keeble
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
| | - Grigoris V Karamasis
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
- Attikon University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - John R Davies
- Essex Cardiothoracic Centre, Basildon University Hospital, Basildon, UK
- Anglia Ruskin University, Chelmsford, UK
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10
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Zhao S, Chen Y, Zhu B, Wang J, Wei Z, Zou Y, Hu W, Chen G, Wang H, Xia C, Yu T, Han P, Yang L, Wang W, Zhai Z, Gao H, Li C, Lian K. Percutaneous coronary intervention improves quality of life of patients with chronic total occlusion and low estimated glomerular filtration rate. Front Cardiovasc Med 2022; 9:1019688. [PMID: 36620621 PMCID: PMC9812571 DOI: 10.3389/fcvm.2022.1019688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background A low estimated glomerular filtration rate (eGFR <90 mL/min/1.73 m2) is widely recognized as a risk factor for major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). However, the impact of successful CTO-PCI on quality of life (QOL) of patients with low eGFR remains unknown. Objectives The aim of this prospective study was to assess the QOL of CTO patients with low eGFR after successful PCI. Methods Consecutive patients undergoing elective CTO-PCI were prospectively enrolled and subdivided into four groups: eGFR ≥90 mL/min/1.73 m2 (n = 410), 90 > eGFR ≥ 60 mL/min/1.73 m2 (n = 482), 60 > eGFR ≥ 30 mL/min/1.73 m2 (n = 161), and eGFR <30 mL/min/1.73 m2 (n = 23). The primary outcomes included QOL, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire, and symptoms, as assessed with the Rose Dyspnea Scale (RDS) and Seattle Angina Questionnaire (SAQ), at 1 month and 1 year after successful PCI. Results With the decline of eGFR, CTO patients were more likely to present with comorbidities of hypertension, diabetes, hyperuricemia, and previous stroke, in addition to lower hemoglobin levels and left ventricular ejection fraction (p < 0.05). Low eGFR was associated with greater incidences of in-hospital pericardiocentesis, major bleeding, acute renal failure, and subcutaneous hematoma, but not in-hospital MACE (p < 0.05). Symptoms of dyspnea and angina were alleviated in all CTO patients with eGFR ≥30 mL/min/1.73 m2 at 1 month and 1 year after successful CTO-PCI, but only at 1 month for those with eGFR <30 mL/min/1.73 m2 (p < 0.01). Importantly, QOL was markedly improved at 1 month and 1 year after successful PCI (p < 0.01), notably at a similar degree between patients with low eGFR and those with normal eGFR (p > 0.05). Conclusion Successful PCI effectively improved symptoms and QOL of CTO patients with low eGFR.
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Affiliation(s)
- Shuai Zhao
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yan Chen
- Department of Cardiology, No. 971 Hospital of the PLA Navy, Qingdao, Shandong, China
| | - Boda Zhu
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China,Primary Flight Training Base, Air Force Aviation University, Harbin, Heilongjiang, China
| | - Jiayi Wang
- Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhihong Wei
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yiming Zou
- Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wentao Hu
- Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Genrui Chen
- Department of Cardiology, Hanyin County People's Hospital, Ankang, Shaanxi, China
| | - Huan Wang
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Chenhai Xia
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Tiantong Yu
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Peng Han
- Department of Cardiology, 981 Hospital of Joint Logistics Support Force, Chengde, Hebei, China
| | - Li Yang
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wei Wang
- Department of Pharmaceutics and Pharmacy Administration, School of Pharmacy, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhongjie Zhai
- Department of Health Statistics, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Haokao Gao
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China,Haokao Gao
| | - Chengxiang Li
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China,Chengxiang Li
| | - Kun Lian
- Department of Cardiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China,*Correspondence: Kun Lian ;
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11
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Poels E, Vanhaverbeke M, van den Buijs D, Cottens D, Ameloot K, Lesizza P, McCutcheon K, Bennet J, Dens J. Postdischarge prognostic significance of periprocedural myocardial injury after percutaneous intervention of chronic total occlusion. Open Heart 2022; 9:openhrt-2022-002113. [PMID: 36600648 PMCID: PMC9748983 DOI: 10.1136/openhrt-2022-002113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The postdischarge prognostic implication of periprocedural myocardial injury in patients undergoing percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) remains scarcely studied. AIMS The aim of this study is to assess the prognostic value of periprocedural myocardial injury, defined by increased high-sensitive troponin T (hs-TnT) levels according to updated guidelines, after CTO PCI. METHODS Between September 2011 and April 2020, 726 patients undergoing CTO PCI at 2 Belgian referral centres were prospectively included and divided into 4 groups based on postprocedural hs-TnT levels (unelevated; ≥5 times the upper limit of normal (ULN); ≥35 times the ULN; ≥70 times the ULN). Postprocedural hs-TnT levels were subsequently related to patient and procedural characteristics, 1-year major adverse cardiac and cerebrovascular events (MACCE; excluding in-hospital MACCE) as well as 1-year mortality. RESULTS At 1 year follow-up (FU), elevated hs-TnT≥5 times and ≥35 times the ULN were associated with higher MACCE rates (p=0.001; p=0.007, respectively). In addition, they also resulted in a higher 1-year mortality rate (p=0.009;p=0.021, respectively). Patients with increased hs-TnT≥5 times the ULN (35% of patients) more frequently had signs of more advanced atherosclerotic disease (previous CABG p<0.001; stroke p≤0.001 and peripheral vascular disease p<0.001) and had higher procedural complexity (Japanese CTO Score p=<0.001, stent length>48 mm p<0.001, procedure time p<0.001). Antegrade wire escalation did not result in lower event rate of postdischarge MACCE compared with the other CTO crossing techniques combined (p=0.158). CONCLUSION Periprocedural myocardial injury was associated with a significantly higher rate of MACCE and all-cause mortality after 12 months of FU.
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Affiliation(s)
- Ella Poels
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Maarten Vanhaverbeke
- Department of Cardiovascular Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | | | - Daan Cottens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Pierluigi Lesizza
- Department of Cardiovascular Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Keir McCutcheon
- Department of Cardiovascular Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Johan Bennet
- Department of Cardiovascular Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Joseph Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
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12
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Zhao S, Chen Y, Wang Q, Zhu B, Wei Z, Wang Z, Wang J, Zou Y, Hu W, Liu C, Yu T, Han P, Yang L, Wang H, Xia C, Liu Q, Wang W, Gao H, Li C, Lian K. Benefits of successful percutaneous coronary intervention in chronic total occlusion patients with diabetes. Cardiovasc Diabetol 2022; 21:271. [PMID: 36471410 PMCID: PMC9724402 DOI: 10.1186/s12933-022-01708-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Diabetes was commonly seen in chronic total occlusion (CTO) patients but data regarding the impact of successful percutaneous coronary intervention (PCI) on clinical outcome of CTO patients with diabetes was controversial. And importantly, no studies have compared quality of life (QOL) after CTO-PCI in patients with and without diabetes. METHODS Consecutive patients undergoing elective CTO-PCI were prospectively enrolled from Apr. 2018 to May 2021. Patients were subdivided into 2 groups: Diabetes and No Diabetes. Detailed baseline characteristics, assessment of symptoms and QOL, angiographic and procedural details, in-hospital complications, and 1 month and 1 year follow-up data were collected. These data were analyzed accordingly for risk predictors of clinical outcome in patients who have diabetes and received successful CTO-PCI. RESULTS A total of 1076 patients underwent CTO-PCI attempts. Diabetes was present in 374 (34.76%) patients, who had more hypertension, previous PCI and stroke. Regarding the coronary lesions, diabetic patients suffered more LCX lesion, multivessel disease, number of lesions per patient, blunt stump, calcification and higher J-CTO score (p < 0.05). In-hospital major adverse cardiac event (MACE) (4.13% vs. 5.35%; p = 0.362) was similar in the two groups. At 1 month and 1 year follow-up after successful CTO-PCI, the incidence of MACE and all-cause mortality were also similar in the two groups (p > 0.05). Number of lesions per patient was an independent risk factor of MACE and all-cause mortality (p < 0.001) 1 year after successful CTO-PCI. Symptom and QOL were markedly improved regardless of diabetes both at 1 month and 1 year follow-up, and importantly, patients with diabetes showed similar degrees of improvement to those without diabetes (P > 0.05). CONCLUSIONS Successful CTO-PCI could represent an effective strategy improving clinical outcome, symptoms and QOL in CTO patients with diabetes.
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Affiliation(s)
- Shuai Zhao
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Yan Chen
- Department of Cardiology, No.971 Hospital of the PLA Navy, Qingdao, 266071 Shandong People’s Republic of China
| | - Qingyi Wang
- grid.233520.50000 0004 1761 4404Department of Foreign Languages, School of Basic Medicine, The Fourth Military Medical University, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Boda Zhu
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China ,Primary Flight Training Base, Air Force Aviation University, Harbin, 150100 Hei Longjiang People’s Republic of China
| | - Zhihong Wei
- grid.233520.50000 0004 1761 4404Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Ziwei Wang
- grid.233520.50000 0004 1761 4404Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Jiayi Wang
- grid.233520.50000 0004 1761 4404Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Yiming Zou
- grid.233520.50000 0004 1761 4404Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Wentao Hu
- grid.233520.50000 0004 1761 4404Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Cheng Liu
- grid.233520.50000 0004 1761 4404Cadet Brigade, School of Basic Medicine, The Fourth Military Medical University, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Tiantong Yu
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Peng Han
- Department of Cardiology, 981 Hospital of Joint Logistics Support Force, Chengde, 067000 Hebei People’s Republic of China
| | - Li Yang
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Huan Wang
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Chenhai Xia
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Qiling Liu
- grid.449637.b0000 0004 0646 966XDepartment of Epidemiology and Medical Statistical, School of Public Health, Shaanxi University of Chinese Medicine, Xianyang, 712046 Shaanxi People’s Republic of China
| | - Wei Wang
- grid.233520.50000 0004 1761 4404Department of Pharmaceutics and Pharmacy Administration, School of Pharmacy, The Fourth Military Medical University, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Haokao Gao
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Chengxiang Li
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China
| | - Kun Lian
- grid.417295.c0000 0004 1799 374XDepartment of Cardiology, Xijing Hospital, The Fourth Military Medical University, 169 West Changle Road, Xi’an, 710032 Shaanxi People’s Republic of China
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13
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Keulards DCJ, Alsanjari O, Keeble TR, Vlaar PJ, Kelly PA, Tang KH, Khan S, Cockburn J, Pijls NHJ, Hildick-Smith D, Teeuwen K, Davies J, Karamasis GV. Changes in coronary collateral function after successful chronic total occlusion percutaneous coronary intervention. EUROINTERVENTION 2022; 18:e920-e928. [PMID: 35994015 PMCID: PMC9743238 DOI: 10.4244/eij-d-22-00118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/15/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) incorporates wire escalation and dissection/re-entry recanalisation strategies. AIMS The purpose of the study was to investigate changes in collateral function after CTO PCI and to identify whether the mode of successful recanalisation influences collateral function regression. METHODS Patients scheduled for elective CTO PCI with evidence of viability in the CTO territory by noninvasive imaging were included in this study. After successful CTO PCI, the aortic pressure (Pa) and distal coronary artery wedge pressure (Pw) during balloon occlusion were measured, both in a resting state and during infusion of intravenous adenosine, allowing the calculation of the pressure-derived collateral pressure index at rest and hyperaemia (CPIrest and the collateral fractional flow reserve [FFRcoll], respectively). Measurements were repeated 3 months later during angiographic follow-up. RESULTS Eighty-one patients had physiological measurements at baseline and follow-up. In the final cohort the mean age was 64 years and 82% were male. The mean maximal stent diameter and total stent length were 3.2±0.5 mm and 68±31 mm, respectively. Successful strategies were antegrade wiring (64.2%), antegrade dissection re-entry (8.6%), and retrograde dissection re-entry (27.1%). Between the index procedure and follow-up, wedge pressure decreased from 34±11 mmHg to 21±8.5 mmHg (p<0.01), respectively. FFRcoll changed from 0.34±0.11 to 0.19±0.09 (p<0.01) at follow-up and CPIrest from 0.40±0.14 to 0.17±0.09 (p<0.01). Absolute maximum collateral flow decreased from 55±32 ml/min directly after PCI to 38±24 ml/min (p<0.01). There was no relation between the recanalisation technique and changes in FFRcoll. CONCLUSIONS There was a significant reduction in collateral flow over time, independent of the recanalisation technique.
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Affiliation(s)
| | - Osama Alsanjari
- Cardiology Department, The Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom
- Anglia Ruskin University School of Medicine, Chelmsford, United Kingdom
- Cardiology Department, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Thomas R Keeble
- Cardiology Department, The Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom
- Anglia Ruskin University School of Medicine, Chelmsford, United Kingdom
| | - Pieter-Jan Vlaar
- Cardiology Department, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Paul A Kelly
- Cardiology Department, The Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom
| | - Kare H Tang
- Cardiology Department, The Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom
| | - Sarosh Khan
- Cardiology Department, The Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom
- Anglia Ruskin University School of Medicine, Chelmsford, United Kingdom
| | - James Cockburn
- Cardiology Department, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Nico H J Pijls
- Cardiology Department, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - David Hildick-Smith
- Cardiology Department, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Koen Teeuwen
- Cardiology Department, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - John Davies
- Cardiology Department, The Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom
- Anglia Ruskin University School of Medicine, Chelmsford, United Kingdom
| | - Grigoris V Karamasis
- Cardiology Department, The Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, United Kingdom
- Anglia Ruskin University School of Medicine, Chelmsford, United Kingdom
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14
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Ybarra LF, Rinfret S. Why and How Should We Treat Chronic Total Occlusion? Evolution of State-of-the-Art Methods and Future Directions. Can J Cardiol 2022; 38:S42-S53. [PMID: 33075456 DOI: 10.1016/j.cjca.2020.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 12/30/2022] Open
Abstract
Chronic total occlusions are considered the most complex coronary lesion in interventional cardiology. The absence of visible lumen on angiography obscures the vessel course and makes vessel wiring unlikely with conventional techniques. Often a source of severe ischemia, chronic occlusions are also markers of advanced atherosclerosis that brings other complex features including lesion length, bifurcations, calcification, adverse vessel remodelling, distal disease, and anatomic distortion from previous bypass grafting. Often advanced atherosclerosis is associated with patient characteristics like left ventricular dysfunction, previous coronary bypass surgery, or multivessel disease that increase procedural demands and hazards. To accommodate these challenges new techniques and dedicated technologies have been developed. When applied to appropriate patients, these advances have improved procedural success, safety, and outcomes. Our aim is to provide the general cardiologist with an overview of these advances that can serve as a basis for counselling patients considered for revascularization.
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Affiliation(s)
- Luiz F Ybarra
- London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Stéphane Rinfret
- Division of Cardiology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.
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15
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Megaly M, Buda K, Karacsonyi J, Kostantinis S, Simsek B, Basir MB, Mashayekhi K, Rinfret S, McEntegart M, Yamane M, Azzalini L, Alaswad K, Brilakis ES. Extraplaque versus intraplaque tracking in chronic total occlusion percutaneous coronary intervention. Catheter Cardiovasc Interv 2022; 100:1021-1029. [PMID: 36168859 DOI: 10.1002/ccd.30403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/29/2022] [Accepted: 09/06/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare the clinical outcomes after extraplaque (EP) versus intraplaque (IP) tracking in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND The impact of modern dissection and reentry (DR) techniques on the long-term outcomes of CTO PCI remains controversial. METHODS We performed a systematic review and meta-analysis of studies that compared EP versus IP tracking in CTO PCI. Odds ratios (ORs) with 95% confidence intervals (CIs) are calculated using the Der-Simonian and Laird random-effects method. RESULTS Our meta-analysis included seven observational studies with 2982 patients. Patients who underwent EP tracking had significantly more complex CTOs with higher J-CTO score, longer lesion length, and more severe calcification and had significantly longer stented segments. During a median follow-up of 12 months (range 9-12 months), EP tracking was associated with a higher risk of major adverse cardiovascular events (MACE) (OR 1.50, 95% CI (1.10-2.06), p = 0.01) and target vessel revascularization (TVR) (OR 1.69, 95% CI (1.15-2.48), p = 0.01) compared with IP tracking. There was no difference in the incidence of all-cause death (OR 1.37, 95% CI (0.67-2.78), p = 0.39), myocardial infarction (MI) (OR 1.48, 95% CI (0.82-2.69), p = 0.20), stent thrombosis (OR 2.09, 95% CI (0.69-6.33), p = 0.19), or cardiac death (OR 1.10, 95% CI (0.39-3.15), p = 0.85) between IP and EP tracking. CONCLUSION EP tracking is utilized in more complex CTOs and requires more stents. EP tracking is associated with a higher risk of MACE, driven by a higher risk of TVR at 1 year, but without an increased risk of death or MI compared with IP tracking. EP tracking is critically important for contemporary CTO PCI.
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Affiliation(s)
- Michael Megaly
- Division of Cardiology, Willis Knighton Heart Institute, Shreveport, Louisiana, USA
| | - Kevin Buda
- Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | | | | | - Bahadir Simsek
- Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Kambis Mashayekhi
- University Heartcenter Freiburg-Bad Krozingen - Bad Krozingen, Germany
| | - Stephane Rinfret
- Department of Cardiology, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Khaldoon Alaswad
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
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16
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Di Mario C, Mashayekhi KA, Garbo R, Pyxaras SA, Ciardetti N, Werner GS. Recanalisation of coronary chronic total occlusions. EUROINTERVENTION 2022; 18:535-561. [PMID: 36134683 DOI: 10.4244/eij-d-21-01117] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning. The contemporary procedural success rate is 80-90% with a reduction in complications. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. Despite this evidence, CTO recanalisation is grossly underutilised. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology.
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Affiliation(s)
- Carlo Di Mario
- Structural Interventional Cardiology Division, Department of Clinical & Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Kambis A Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Roberto Garbo
- GVM Care & Research, Maria Pia Hospital, Turin, Italy
| | | | - Niccolò Ciardetti
- Structural Interventional Cardiology Division, Department of Clinical & Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Gerald S Werner
- Department of Cardiology, Klinikum Darmstadt GmbH, Darmstadt, Germany
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17
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Wilgenhof A, Vescovo GM, Bezzeccheri A, Scott B, Vermeersch P, Convens C, Verheye S, Zivelonghi C, Agostoni P. Minimalistic hybrid approach for the percutaneous treatment of chronic coronary total occlusions: An in-depth analysis of the whole algorithm. Catheter Cardiovasc Interv 2022; 100:502-511. [PMID: 35900200 DOI: 10.1002/ccd.30352] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/06/2022] [Accepted: 07/16/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The minimalistic hybrid approach (MHA) is an algorithm to perform chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The current study aims to evaluate the distribution of patients among the five different treatment strategies, the different techniques used in each strategy, the overall procedural success, and the safety of the MHA algorithm. METHODS Data from a consecutive series of patients with a CTO who underwent elective PCI between February 2019 and July 2021 were prospectively collected and retrospectively analyzed. RESULTS One hundred and forty-three CTOPCI in 135 patients were approached according to the MHA algorithm: 134 CTO (93.7%) were successfully recanalized and 9 procedures failed. About half of the procedures (48.3%) were approached using strategy A: antegrade "blind wiring" with contralateral retrograde options, making this the most popular strategy. A total of 89 procedures (62.2%) were completed with a single guiding catheter; in 86 (96.6%) a forearm approach was used. The remaining 54 cases were performed with dual access; in the majority of these patients (90.7%), a bilateral forearm approach was used. The only reason to use the femoral access was inadequate forearm access. One hundred and fifty-four out of 197 (78.2%) access sites were 6 French sheaths. CONCLUSION MHA is a stepwise approach focused on the forearm approach to reduce the number of access sites and catheter size used in CTOPCI while maintaining proficiency and safety. Operators should be warned that this approach should be adopted only by experienced CTO operators who master all the strategies of the classic hybrid algorithm and the forearm approach.
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Affiliation(s)
- Adriaan Wilgenhof
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Giovanni Maria Vescovo
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium.,Interventional Cardiology, Department of Cardiothoracic and Vascular Science, Ospedale dell'Angelo, Venice, Italy
| | - Andrea Bezzeccheri
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium.,Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Benjamin Scott
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Paul Vermeersch
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Carl Convens
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Stefan Verheye
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Carlo Zivelonghi
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
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18
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Azzalini L, Karmpaliotis D, Santiago R, Mashayekhi K, Di Mario C, Rinfret S, Nicholson WJ, Carlino M, Yamane M, Tsuchikane E, Brilakis ES. Contemporary Issues in Chronic Total Occlusion Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2022; 15:1-21. [PMID: 34991814 DOI: 10.1016/j.jcin.2021.09.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/26/2021] [Accepted: 09/21/2021] [Indexed: 12/18/2022]
Abstract
Remarkable progress has been achieved in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in recent years, with refinement of the indications and technical aspects of the procedure, imaging, and complication management. Randomized controlled trials and rigorous prospective registries have provided high-quality data on the benefits and risks of CTO PCI. Global collaboration has led to an agreement on nomenclature, indications, endpoint definition, and principles of clinical trial design that have been distilled in global consensus documents such as the CTO Academic Research Consortium. Increased use of preprocedural coronary computed tomography angiography and intraprocedural intravascular imaging, as well as development of novel techniques and structured CTO crossing and complication management algorithms, allow a systematic, stepwise approach to this difficult lesion subset. This state-of-the-art review provides a comprehensive discussion about the most recent developments in the indications, preprocedural planning, technical aspects, complication management, and future directions of CTO PCI.
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Affiliation(s)
- Lorenzo Azzalini
- Division of Cardiology, VCU Health Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA.
| | - Dimitri Karmpaliotis
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Ricardo Santiago
- PCI Cardiology Group, Bayamon Heart and Lung Institute, Bayamon, Puerto Rico, USA
| | - Kambis Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Carlo Di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Department of Clinical & Experimental Medicine, Florence, Italy
| | | | | | - Mauro Carlino
- Interventional Cardiology Division, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Masahisa Yamane
- Cardiovascular Division, Saitama-Sekishinkai Hospital, Saitama, Japan
| | | | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
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19
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Update on chronic total occlusion percutaneous coronary intervention. Prog Cardiovasc Dis 2021; 69:27-34. [PMID: 34826426 DOI: 10.1016/j.pcad.2021.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/14/2021] [Indexed: 11/22/2022]
Abstract
Chronic total occlusion (CTO) percutaneous coronary interventions (PCI) can be challenging to perform. The main indication for CTO PCI is to improve symptoms. Several contemporary studies have reported high CTO PCI success rates at experienced centers but success rates in all-comer registries remain low. Several scores can estimate the difficulty and the likelihood of success of CTO PCI. Dual arterial access and use of CTO crossing algorithms can improve the success and safety of CTO PCI. Intracoronary imaging can optimize stent expansion and minimize adverse cardiovascular events. While complications are more common in CTO PCI, careful planning and prompt diagnosis and treatment can prevent them or minimize their adverse consequences. In this article, we review contemporary data on the indications, safety and efficacy of CTO PCI.
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20
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Xhepa E, Cassese S, Ndrepepa G, Joner M, Kufner S, Aytekin A, Lahmann A, Voll F, Fusaro M, Pinieck S, Schunkert H, Kastrati A, Fusaro M. Clinical and angiographic outcomes of crossing techniques for coronary chronic total occlusions: the ISAR-CTO registry. EUROINTERVENTION 2021; 17:e656-e663. [PMID: 33646124 PMCID: PMC9724870 DOI: 10.4244/eij-d-20-01248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clinical and angiographic outcomes following recanalisation of coronary chronic total occlusions (CTO) through contemporary dissection and re-entry techniques (DART) as opposed to intraplaque techniques remain controversial. AIMS The aim of this study was to compare clinical and angiographic outcomes following subintimal and intraplaque CTO recanalisation. METHODS A total of 454 consecutive patients undergoing successful CTO recanalisation (473 vessels) were included. Intraplaque techniques were used in 403 (85.2%) and DART in 70 (14.8%) vessels. Surveillance angiography was scheduled at 6-9 months and clinical follow-up was performed up to 12 months. RESULTS There were no significant differences in terms of the cumulative incidence of MACE (p=0.908) or binary restenosis (p=0.320) between the two groups. There was no independent correlation between recanalisation technique and MACE occurrence or in-segment binary restenosis. Target lesion revascularisation (TLR) was performed in 60 (17.5%) and 12 (18.1%) (p=0.719) lesions, respectively. The occurrence of occlusive restenosis was low (7 [2.3%] vs 1 [1.6%]; p=0.824) and comparable between groups. CONCLUSIONS Contemporary DART are associated with similar midterm clinical and angiographic outcomes compared to intraplaque recanalisation. The rate of occlusive restenosis was low and comparable in both groups. Regardless of recanalisation technique, the overall incidences of binary restenosis and TLR following CTO recanalisation remain higher than those reported for non-CTO PCI.
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Affiliation(s)
- Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany,Deutsches Zentrum für Herz- und Kreislauf-Forschung (DZHK) e.V. (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Sebastian Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alp Aytekin
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Anna Lahmann
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Felix Voll
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michele Fusaro
- Department of Diagnostic and Interventional Radiology, Santa Maria di Ca' Foncello Hospital, Treviso, Italy
| | - Susanne Pinieck
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany,Deutsches Zentrum für Herz- und Kreislauf-Forschung (DZHK) e.V. (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany,Deutsches Zentrum für Herz- und Kreislauf-Forschung (DZHK) e.V. (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Massimiliano Fusaro
- Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstrasse 36, 80636 Munich, Germany
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21
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Xu T, Feng B, Zheng Z, Li L, Zeng W, Wang D, Zhang L, Li H. Association of stent diameter and target vessel revascularization in patients undergoing percutaneous coronary intervention: a secondary retrospective analysis based on a Chinese cohort study. BMC Cardiovasc Disord 2021; 21:402. [PMID: 34418965 PMCID: PMC8379726 DOI: 10.1186/s12872-021-02212-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background In the treatment of coronary heart disease, target vessel revascularization (TVR) has attracted increasing attention as an efficient means of percutaneous coronary intervention (PCI). The purpose of this study was to explore the association between stent diameter and TVR in patients undergoing PCI. Methods This was a secondary retrospective analysis involving patients with PCI with at least one stent implanted. Information was obtained from the Dryad Digital Repository. Multivariable logistic regression models, interaction analyses, subgroup analyses and piecewise linear regression models were used to evaluate the association between stent diameter and TVR. Results A total of 2522 patients were eventually enrolled in this study, of which 122 (4.8%) had undergone TVR. Significant positive associations were observed between stent diameter and TVR (continuous: odds ratio [OR] 0.485, 95% confidence interval [CI] 0.305–0.773, P = 0.002; categorical variable: T2 vs. T1, OR 0.541, 95% CI 0.348–0.843; T3 vs. T1, OR 0.520, 95% CI 0.334–0.809; P for trend = 0.005). The association remained stable in the fully adjusted model (continuous: OR 0.526, 95% CI 0.306–0.902, P = 0.020; categorical variable: T2 vs. T1, OR 0.510, 95% CI 0.310–0.839; T3 vs. T1, OR 0.585, 95% CI 0.352–0.973; P for trend = 0.042). Among the subgroups of differing clinical presentations, stent diameter was a powerful protective factor for TVR, especially in the delayed PCI group (P for interaction = 0.002). The association was highly consistent across all the other subgroups studied (all P for interaction > 0.05). In the piecewise linear regression model, the need for TVR decreased with an increase in stent diameter when this ranged between 2.5 and 2.9 mm (OR 0.01, 95% CI: 0.01–0.13, P < 0.001). Conclusions A large stent diameter is a powerful protective factor for TVR in PCI patients, especially in the delayed PCI group. This “bigger-is-better” protective effect is remarkable in stents with diameter 2.5–2.9 mm.
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Affiliation(s)
- Tiancheng Xu
- Department of Cardiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, No. 41 Northwest Street, Haishu District, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Beili Feng
- Department of Cardiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, No. 41 Northwest Street, Haishu District, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Zaixing Zheng
- Department of Cardiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, No. 41 Northwest Street, Haishu District, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Licheng Li
- Department of Cardiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, No. 41 Northwest Street, Haishu District, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Weifang Zeng
- Department of Cardiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, No. 41 Northwest Street, Haishu District, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Dongjuan Wang
- Department of Cardiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, No. 41 Northwest Street, Haishu District, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Lin Zhang
- Department of Cardiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, No. 41 Northwest Street, Haishu District, Ningbo, 315000, Zhejiang, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China
| | - Hengdong Li
- Department of Cardiology, Hwa Mei Hospital, University of Chinese Academy of Sciences, No. 41 Northwest Street, Haishu District, Ningbo, 315000, Zhejiang, China. .,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, 315000, Zhejiang, China.
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22
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Voll F, Kuna C, Kufner S, Cassese S. [Technical armamentarium for chronic total occlusion of coronary vessels]. Herz 2021; 46:406-418. [PMID: 34398249 DOI: 10.1007/s00059-021-05053-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/28/2022]
Abstract
Percutaneous revascularization of chronic total occlusion (CTO) of coronary vessels represents a major challenge for contemporary interventional cardiologists. In the last decade there has been an unprecedented effort towards the standardization of revascularization procedures for CTO of coronary vessels. This endeavour has been possible by virtue of the growing interest of various cardiological societies for this patient group. Along with supportive endovascular technologies and percutaneous devices specifically dedicated to this interventional target, the increasing experience of interventionalists enabled continuously growing success for revascularization of CTO of coronary vessels. This review article highlights the currently available tools as well as technologies, techniques and strategies for the percutaneous recanalization of CTO of coronary vessels.
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Affiliation(s)
- F Voll
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, München, Deutschland
| | - C Kuna
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, München, Deutschland
| | - S Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, München, Deutschland
| | - S Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Lazarettstraße 36, München, Deutschland.
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23
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Azzalini L, Moroni F, Santiago R. Subintimal shift at the bifurcation: A cause of side branch occlusion in chronic total occlusion intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40S:298-301. [PMID: 34215558 DOI: 10.1016/j.carrev.2021.06.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/16/2021] [Accepted: 06/24/2021] [Indexed: 11/03/2022]
Abstract
Bifurcation lesions are frequently found in chronic total occlusion (CTO) percutaneous coronary intervention and are associated with lower procedural success and higher rates of complications, including side branch loss. In this report, we describe a poorly understood mechanism for side branch loss in CTO PCI: subintimal shift. This involves the extension of a dissection plane caused by subintimal (extraplaque) crossing in the main branch at the level of the side branch ostium, causing exclusion of the latter upon vessel preparation or stent placement. Subintimal shift (as compared to carina shift in non-CTO bifurcation intervention) appears to be under-recognized, and CTO operators should be aware that, from a technical standpoint, ballooning of the side branch is unlikely to restore and maintain flow, and a two-stent strategy is indicated to preserve the bifurcation.
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Affiliation(s)
- Lorenzo Azzalini
- Division of Cardiology, VCU Health Pauley Heart Center, Richmond, VA, USA; Virginia Commonwealth University, Richmond, VA, USA.
| | - Francesco Moroni
- Division of Cardiology, VCU Health Pauley Heart Center, Richmond, VA, USA; Virginia Commonwealth University, Richmond, VA, USA; Università Vita-Salute San Raffaele, Milan, Italy
| | - Ricardo Santiago
- PCI Cardiology Group, Bayamon Heart and Lung Institute, Bayamon, PR, USA; PCI Cardiology Group, Manatí Cardiovascular Interventional Institute, Manatí, PR, USA
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24
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Ciardetti N, Mattesini A, Di Mario C. Going through or around the occlusion? All roads lead to Rome. Cardiol J 2021; 28:355-357. [PMID: 34046878 DOI: 10.5603/cj.2021.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Niccolò Ciardetti
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Alessio Mattesini
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy.
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25
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Mahadevan K, Cosgrove C, Strange JW. Factors Influencing Stent Failure in Chronic Total Occlusion Coronary Intervention. Interv Cardiol 2021; 16:e27. [PMID: 34721666 PMCID: PMC8532005 DOI: 10.15420/icr.2021.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/07/2021] [Indexed: 11/04/2022] Open
Abstract
Stent failure remains one of the greatest challenges for interventional cardiologists. Despite the evolution to superior second- and third-generation drug-eluting stent designs, increasing use of intracoronary imaging and the adoption of more potent antiplatelet regimens, registries continue to demonstrate a prevalence of stent failure or target lesion revascularisation of 15-20%. Predisposition to stent failure is consistent across both chronic total occlusion (CTO) and non-CTO populations and includes patient-, lesion- and procedure-related factors. However, histological and pathophysiological properties specific to CTOs, alongside complex strategies to treat these lesions, may potentially render percutaneous coronary interventions in this cohort more vulnerable to failure. Prevention requires recognition and mitigation of the precipitants of stent failure, optimisation of interventional techniques, including image-guided precision percutaneous coronary intervention, and aggressive modification of a patient's cardiovascular risk factors. Management of stent failure in the CTO population is technically challenging and itself begets recurrence. We aim to provide a comprehensive review of factors influencing stent failure in the CTO population and strategies to attenuate these.
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Affiliation(s)
- Kalaivani Mahadevan
- Department of Cardiology, University Hospitals Bristol and Weston NHS Foundation TrustBristol, UK
| | - Claudia Cosgrove
- Department of Cardiology, St George’s University NHS TrustLondon, UK
| | - Julian W Strange
- Department of Cardiology, University Hospitals Bristol and Weston NHS Foundation TrustBristol, UK
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26
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Bryniarski L, Opolski MP, Wójcik J, Lesiak M, Pawłowski T, Drozd J, Wojakowski W, Surowiec S, Dąbrowski M, Witkowski A, Dudek D, Grygier M, Bartuś S. Chronic total occlusion percutaneous coronary intervention in everyday clinical practice - an expert opinion of the Association of Cardiovascular Interventions of the Polish Cardiac Society. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 17:6-20. [PMID: 33868413 PMCID: PMC8039914 DOI: 10.5114/aic.2021.104763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Leszek Bryniarski
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maksymilian P. Opolski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Jarosław Wójcik
- Hospital of Invasive Cardiology IKARDIA, Lublin/Nałęczów, Poland
| | - Maciej Lesiak
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Pawłowski
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Jakub Drozd
- Department of Cardiology, SP ZOZ MSWiA, Lublin, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Sławomir Surowiec
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej Dąbrowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Dariusz Dudek
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Grygier
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Stanisław Bartuś
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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27
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Ybarra LF, Rinfret S, Brilakis ES, Karmpaliotis D, Azzalini L, Grantham JA, Kandzari DE, Mashayekhi K, Spratt JC, Wijeysundera HC, Ali ZA, Buller CE, Carlino M, Cohen DJ, Cutlip DE, De Martini T, Di Mario C, Farb A, Finn AV, Galassi AR, Gibson CM, Hanratty C, Hill JM, Jaffer FA, Krucoff MW, Lombardi WL, Maehara A, Magee PFA, Mehran R, Moses JW, Nicholson WJ, Onuma Y, Sianos G, Sumitsuji S, Tsuchikane E, Virmani R, Walsh SJ, Werner GS, Yamane M, Stone GW, Rinfret S, Stone GW. Definitions and Clinical Trial Design Principles for Coronary Artery Chronic Total Occlusion Therapies: CTO-ARC Consensus Recommendations. Circulation 2021; 143:479-500. [PMID: 33523728 DOI: 10.1161/circulationaha.120.046754] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Over the past 2 decades, chronic total occlusion (CTO) percutaneous coronary intervention has developed into its own subspecialty of interventional cardiology. Dedicated terminology, techniques, devices, courses, and training programs have enabled progressive advancements. However, only a few randomized trials have been performed to evaluate the safety and efficacy of CTO percutaneous coronary intervention. Moreover, several published observational studies have shown conflicting data. Part of the paucity of clinical data stems from the fact that prior studies have been suboptimally designed and performed. The absence of standardized end points and the discrepancy in definitions also prevent consistency and uniform interpretability of reported results in CTO intervention. To standardize the field, we therefore assembled a broad consortium comprising academicians, practicing physicians, researchers, medical society representatives, and regulators (US Food and Drug Administration) to develop methods, end points, biomarkers, parameters, data, materials, processes, procedures, evaluations, tools, and techniques for CTO interventions. This article summarizes the effort and is organized into 3 sections: key elements and procedural definitions, end point definitions, and clinical trial design principles. The Chronic Total Occlusion Academic Research Consortium is a first step toward improved comparability and interpretability of study results, supplying an increasingly growing body of CTO percutaneous coronary intervention evidence.
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Affiliation(s)
- Luiz F Ybarra
- London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada (L.F.Y.)
| | - Stéphane Rinfret
- McGill University Health Centre, McGill University, Montreal, Quebec, Canada (S.R.)
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (E.S.B.)
| | - Dimitri Karmpaliotis
- New York-Presbyterian Hospital/Columbia University Medical Center, NY (D.K., Z.A.A., A.M., J.W.M.).,The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.)
| | - Lorenzo Azzalini
- Cardiac Catheterization Laboratory, Mount Sinai Hospital, New York, NY (L.A.)
| | - J Aaron Grantham
- Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.G.)
| | | | - Kambis Mashayekhi
- Department of Cardiology and Angiology II University Heart Center (K.M.), Freiburg, Bad Krozingen, Germany
| | - James C Spratt
- St George's University Hospital NHS Trust, London, United Kingdom (J.C.S.)
| | - Harindra C Wijeysundera
- Schulich Heart Center, Sunnybrook Research Institute, and Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, and Institute for Health Policy, Management, and Evaluation (H.C.W.), University of Toronto, Ontario, Canada
| | - Ziad A Ali
- New York-Presbyterian Hospital/Columbia University Medical Center, NY (D.K., Z.A.A., A.M., J.W.M.).,The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.)
| | | | - Mauro Carlino
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy (M.C.)
| | - David J Cohen
- Baim Institute for Clinical Research, Boston, MA (D.J.C., C.M.G.)
| | | | - Tony De Martini
- Southern Illinois University School of Medicine, Memorial Medical Center, Springfield, IL (T.D.M.)
| | - Carlo Di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy (C.D.M.)
| | - Andrew Farb
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD (A.F., R.V.).,School of Medicine, University of Maryland, Baltimore (A.F.)
| | - Aloke V Finn
- US Food and Drug Administration, Silver Spring, MD (A.V.F., P.F.A.M.)
| | - Alfredo R Galassi
- Cardiology, Department of PROMISE, University of Palermo, Italy (A.R.G.)
| | - C Michael Gibson
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.J.C., C.M.G.)
| | - Colm Hanratty
- Belfast Health and Social Care Trust, United Kingdom (C.H.)
| | | | - Farouc A Jaffer
- Cardiology Division, Massachusetts General Hospital, Boston (F.A.J.)
| | - Mitchell W Krucoff
- Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (M.W.K.)
| | | | - Akiko Maehara
- New York-Presbyterian Hospital/Columbia University Medical Center, NY (D.K., Z.A.A., A.M., J.W.M.).,The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.)
| | - P F Adrian Magee
- US Food and Drug Administration, Silver Spring, MD (A.V.F., P.F.A.M.)
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
| | - Jeffrey W Moses
- New York-Presbyterian Hospital/Columbia University Medical Center, NY (D.K., Z.A.A., A.M., J.W.M.).,The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.)
| | | | - Yoshinobu Onuma
- Cardialysis Clinical Trials Management and Core Laboratories, Rotterdam, the Netherlands (Y.O.).,Department of Cardiology, National University of Ireland Galway, United Kingdom (Y.O.)
| | | | - Satoru Sumitsuji
- Division of Cardiology for International Education and Research, Osaka University Graduate School of Medicine, Suita, Japan (S.S.)
| | | | - Renu Virmani
- Department of Cardiovascular Pathology, CVPath Institute, Gaithersburg, MD (A.F., R.V.)
| | - Simon J Walsh
- Belfast Health and Social Care Trust, United Kingdom. Medizinische Klinik I Klinikum Darmstadt GmbH, Germany (S.J.W.)
| | | | | | - Gregg W Stone
- The Cardiovascular Research Foundation, New York, NY (D.K., A.M., Z.A.A., J.W.M., G.W.S.).,Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
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28
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Yoon YH, Lee PH, Park TK, Lee JH, Cho YR, Suh J, Roh JH, Lee JH, Yoon CH, Hong YJ, Lee CH, Her SH, Chun KJ, Yoo SY, Lee JY, Lee SW. Technical Feasibility and Safety of Percutaneous Coronary Intervention for True Ostial Left Anterior Descending Artery-Chronic Total Occlusion. Can J Cardiol 2020; 37:458-466. [PMID: 32827638 DOI: 10.1016/j.cjca.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) for true ostial left anterior descending artery (LAD)-chronic total occlusion (CTO) lesions poses technical challenges owing to its inherent anatomic features. METHODS In total, 270 consecutive patients who underwent PCI for ostial LAD-CTO at 13 major cardiac centers in South Korea were included. Ostial LAD-CTO was strictly defined as a LAD-CTO lesion whose proximal cap was within 1 mm from the carina of the distal left main coronary artery (LMCA) bifurcation. RESULTS Ostial LAD-CTOs were frequently accompanied by stumpless lesion entry (43.4%), whereas significant bending within the occluded segment was less frequent (14.4%). The overall technical success rate was 85.9%, and serious in-hospital adverse events occurred in 5.6%. The retrograde approach tended to contribute more frequently to success in patients with concomitant LMCA disease, stumpless CTO, interventional collaterals, and higher Japanese-CTO scores. Apparent dissection or hematoma requiring rescue procedure at the LMCA or left circumflex artery occurred in 14 patients (5.2%), with a higher tendency in patients who had LMCA disease (12.1% vs 4.2%) and stumpless entry (9.4% vs 2.0%) than in those without. Among patients who were successfully treated, with an average of 1.7 stents, target-vessel failure occurred in 23 patients (9.9%) during a median 3.3 years of follow-up. CONCLUSIONS In this first large-scale analysis of true ostial LAD-CTO, PCI was feasible with a high technical success rate and favourable mid-term outcomes. Clinically relevant inflow vessel injury can occur during PCI and should be an important technical consideration regarding safety.
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Affiliation(s)
- Yong-Hoon Yoon
- Division of Cardiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jang Hoon Lee
- Division of Cardiology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Young-Rak Cho
- Department of Cardiology, Dong-A University Hospital, Busan, Korea
| | - Jon Suh
- Department of Cardiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jae-Hyung Roh
- Division of Cardiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae-Hwan Lee
- Division of Cardiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Chang-Hwan Yoon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Joon Hong
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Cheol Hyun Lee
- Division of Cardiology, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Sung-Ho Her
- Department of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Kook-Jin Chun
- Division of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang-Yong Yoo
- Cardiovascular Center, Gangneung Asan Hospital, Gangneung, Korea
| | - Jong-Young Lee
- Division of Cardiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Seung-Whan Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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29
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Creaney C, Walsh SJ. Antegrade Chronic Total Occlusion Strategies: A Technical Focus for 2020. ACTA ACUST UNITED AC 2020; 15:e08. [PMID: 32684982 PMCID: PMC7362334 DOI: 10.15420/icr.2020.05] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/24/2020] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Calum Creaney
- Department of Cardiology, Belfast Health and Social Care Trust Belfast, UK
| | - Simon J Walsh
- Department of Cardiology, Belfast Health and Social Care Trust Belfast, UK
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30
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Mintz GS. Back to the Future: Intravascular Imaging to Assess and Guide CTO PCI Procedures. JACC Cardiovasc Interv 2020; 13:1458-1459. [PMID: 32553334 DOI: 10.1016/j.jcin.2020.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Gary S Mintz
- Cardiovascular Research Foundation, New York, New York.
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