Coronary Chronic Total Occlusion Recanalisation - Current Techniques and Approaches

Defining Key Features of Complex Coronary Lesions: An Evidence Based Review of Clinical Practice. Part II: Chronic Total Occlusions, Graft Interventions, In-Stent Restenosis, and Antithrombotic Strategies

Clinicians have long recognized that certain features of coronary artery lesions increase the complexity of intervention. Complex lesions are associated with worse cardiovascular outcomes and a higher risk of subsequent ischemic events. These lesions are categorized by their angiographic features. These features include bifurcation lesions, left main coronary artery disease, calcified lesions, in-stent restenosis, chronic total occlusions and graft interventions. This two-part review aims to highlight the current evidence in the percutaneous management of these lesions. Part two of this review focuses on the indications to treat chronic total occlusions, interventions of failed grafts, tools used to treat in-stent restenosis, as well as antithrombotic strategies.

The Hybrid Approach and Its Variations for Chronic Total Occlusion Percutaneous Coronary Intervention

Selected patients with coronary chronic total occlusion (CTO) benefit with respect to symptoms, quality of life, ischemia reduction, and potentially longevity among other benefits. CTO lesions tend to be the most technically challenging for practicing interventional cardiologists to deliver a successful and safe result and clinical experience for a given patient. The Hybrid algorithm for CTO percutaneous coronary intervention and the subsequent subalgorithms for focused technical challenges have a standardized process and provide a consistent platform for optimized patient care, medical education, and clinical investigation in patients challenged with total occlusion and complex coronary disease.

A Novel Strategy for Chronic Total Occlusion of the Stumpless Ostial Left Anterior Descending Artery

BACKGROUND Despite improvements in percutaneous coronary intervention (PCI) devices and operator expertise, coronary chronic total occlusion (CTO) poses a management dilemma for interventional cardiologists. Occasionally, in CTO lesions and in bifurcation lesions with severe curvature and stenosis, wires cannot be introduced into the main artery, although wiring into the side branch is possible. We herein report a case of stumpless ostial left anterior descending artery (LAD) CTO that was successfully treated with a novel strategy. CASE REPORT A 64-year-old female with symptoms of heart failure was admitted to our hospital. Coronary angiography showed CTO of the stumpless ostial LAD. The patient had invisible and continuous collaterals; therefore, we used the antegrade approach for CTO access. However, the wire could be guided only in the direction of the diagonal branch due to a severe angulation at the CTO exit site, despite successful wire crossing into the CTO lesion. We attempted intravascular ultrasound-guided direct wire entry technique to obtain additional information about the occlusion cap location and to assist in negotiating the wire into the true lumen. The guidewire (Conquest pro) could cross the lesion after several approaches and successfully advance the device over the wire through the occluded segment after the modified See-saw wiring technique was employed. CONCLUSIONS This method appears to be a promising novel strategy for difficult and complex lesions when performing CTO revascularization.