Value of different CTO scoring systems in predicting procedural success in coronary chronic total occlusion intervention in Egyptian patients

BACKGROUND

Chronic total occlusion (CTO) lesions in coronary arteries pose a significant challenge for coronary interventionists, often leading to referrals for coronary artery bypass graft surgery (CABG). Successful percutaneous coronary intervention (PCI) for CTOs requires accurate assessment of procedural potential. This study, comprising 100 Egyptian patients aged 37-81, compares the predictive efficacy of various CTO scoring systems in PCI success determination. Patients with CTO in at least one coronary artery, planned for elective PCI based on objective evidence of ischemia, were included. Experienced operators performed PCI, recording procedural variables, and assessing complications. Logistic regression analysis revealed an inverse linear relationship between success rates and score values across all systems.

RESULTS

Although, the predictive capacity of the scores was similar, with slight differences. The Euro CTO (CASTLE) score10 exhibited superior predictive efficacy, followed by the CL score9, while PROGRESS8 and J-CTO7 scores showed lower significance. ORA CTO11 score demonstrated intermediate predictive ability, and PROGRESS score8 had the least predictive value.

CONCLUSION

The CASTLE score10 proved most effective in predicting PCI success for CTO cases in Egyptian patients, with operators advised to choose scoring systems based on experience and case characteristics. Proper planning remains crucial for optimizing success rates in CTO PCI procedures, irrespective of the scoring system employed.

Outcomes of chronic total occlusion percutaneous coronary intervention from the RAIAN (RAjaie - Iran) registry

OBJECTIVE

While most of the evidence in CTO interventions emerge from Western and Japanese studies, few data have been published up today from the Middle East. Objective of this study was to evaluate technical success rates and clinical outcomes of an Iranian population undergoing CTO PCI in a tertiary referral hospital. Moreover, we sought to evaluate the efficacy of our CTO teaching program.

METHODS

This is a retrospective single-center cohort study including 790 patients who underwent CTO PCI performed by operators with different volumes of CTOs PCI performed per year. According to PCI result, all patients have been divided into successful (n = 555, 70.3 %) and unsuccessful (n = 235, 29.7 %) groups. Study endpoints were Major Adverse Cardiovascular Events and Health Status Improvement evaluated using the Seattle Angina Questionnaire at one year.

RESULTS

A global success rate of 70 % for antegrade and 80 % for retrograde approach was shown despite the lack of some CTO-dedicated devices. During the enrollment period, the success rate increased significantly among operators with a lower number of CTO procedures per year. One-year MACE rate was similar in both successful and unsuccessful groups (13.5 % in successful and 10.6 % in unsuccessful group, p = 0.173). One year patients' health status improved significantly only in successful group.

CONCLUSIONS

No significant differences of in-hospital and one-year MACE were found between the successful and unsuccessful groups. Angina symptoms and quality of life significantly improved after successful CTO PCI. The RAIAN registry confirmed the importance of operator expertise for CTO PCI success.

Chronologic evolution and prognostic implications of impaired coronary flow after chronic total occlusion angioplasty

Background

Although vessels have the potential to recover following successful recanalization of chronic total occlusion (CTO), evidence is limited about the clinical significance of slow flow (SF) phenomenon after recanalization. The aim of this study was to evaluate the determinants, development and prognostic impact of SF after percutaneous coronary intervention (PCI) for CTO.

Methods

This was a retrospective cohort study, 500 patients were consecutively enrolled undergoing CTO PCI and consecutive follow-up angiography in Zhongshan Hospital, Fudan University, between 2015 and 2020. Coronary flow was assessed by corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (CTFC). The association between SF and outcomes of CTO PCI was evaluated by analyzing the clinical, angiographic, and procedural characteristics.

Results

SF was observed in 29 (5.8%) patients immediately after CTO PCI. Prior myocardial infraction, right coronary artery (RCA) revascularization and lack of bilateral collaterals were independent predictors of SF. SF was associated with increased risks of periprocedural myocardial infarction (PMI) [adjusted odds ratio (adOR): 4.12; 95% confidence interval (CI): 1.68-10.07; P=0.002] and target lesion restenosis (adOR: 2.50; 95% CI: 1.10-5.72; P=0.030). In patients with baseline left ventricular ejection fraction (LVEF) ≤60%, systolic improvement was compromised in the SF group (LVEF: 55.4%±9.6% in follow up vs. 52.1%±9.4% before CTO PCI, P=0.147) compared with that of the normal group (LVEF: 55.7%±9.3% vs. 51.6%±8.5%, P<0.001).

Conclusions

SF has a significant influence on the prognosis of patients undergoing CTO PCI. Achieving normal coronary flow is essential in CTO revascularization.

Evaluation of right-ventricular function by two-dimensional echocardiography and two-dimensional speckle-tracking echocardiography in patients with successful RCA CTO recanalization

OBJECTIVES

Chronic total occlusion (CTO) of the right coronary artery (RCA) is common in patients with coronary artery disease. Although revascularization techniques and success rates have improved significantly in recent years, there are still no studies investigating possible effects of successful recanalization of RCA CTO on the right-ventricular (RV) function. With this study, we aimed to evaluate RV function after recanalization of the RCA by two-dimensional transthoracic echocardiography (2DE) and additional two-dimensional speckle-tracking echocardiography (2DSTE).

METHODS AND RESULTS

Our analysis included 102 patients undergoing successful RCA CTO recanalization at the University Medical Center of Mainz. All patients underwent 2DE and 2DSTE to assess RV function before PCI procedure and 6 months after successful revascularization. We found an altered RV function in our collective at baseline assessed by 2DSTE with a significant improvement at 6 month follow-up (baseline RV free wall strain: - 20.7 [- 6.3 to - 32.0] % vs. - 23.4 [- 8.3 to - 39.3] % at follow-up, p < 0.001 and baseline RV global strain - 15.9 [- 6.0 to - 25.7] % vs. - 17.9 [- 7.0 to - 29.5] % at follow-up, p < 0.001).

CONCLUSION

RV function was altered in patients with RCA CTO and showed significant improvement after successful recanalization. We also noticed an improvement in patient-reported clinical symptoms. Our study suggests that CTO procedure is a beneficial treatment option in symptomatic patients with RCA CTO.

Temporal trends of case-fatality in patients undergoing dual-injection coronary chronic total occlusion recanalization

AIMS

Recently, interventional techniques and material to treat chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) have evolved significantly. Nevertheless, it is still unknown whether this progress improved treatment success and patients' outcome. In a nationwide sample, we sought to analyze trends of patients' characteristics, complications and in-hospital case-fatality of patients undergoing CTO revascularization in Germany.

METHODS AND RESULTS

We analyzed data on characteristics, treatments, and in-hospital outcomes for all coronary artery disease (CAD) patients (ICD-code I25) undergoing dual-injection CTO recanalization (OPS procedural code: 8-839.9) in Germany from 2009 to 2020. Overall, 4,998,457 inpatients aged ≥ 18 years with diagnosis of CAD were treated in German hospitals in this period. Among these, 52,879 patients (1.1%) underwent CTO recanalization. Annual number of CTO PCIs increased from 1263 in 2009 to 6435 in 2020 (β 3.48 [95% CI 3.44-3.52]; p < 0.001) in parallel with a significant decrease of case-fatality (2.2% in 2009 to 1.4% in 2020; β  - 0.60 [95% CI  - 0.82 to  - 0.39]; p < 0.001). Overall, 754 (1.4%) patients with CTO recanalization died during the in-hospital stay and in-hospital case-fatality grew exponentially with age (β 0.82 [95% CI 0.73-0.90]; p < 0.001). Significant predictors of in-hospital case fatality with an OR > 3 were cancer, stroke, hemopericardium, acute renal failure, pulmonary embolism and shock.

CONCLUSION

Annual number of CTO procedures performed in Germany increased from 2009 to 2020 with a concomitant anti-proportional decrease in the case-fatality. Our findings may help to draw more attention to predictors of in-hospital case fatality in patients hospitalized for CTO recanalization.

"Double Tip-in" Technique to Facilitate Retrograde Chronic Total Occlusion Approach

"Tip-in" technique used in chronic total occlusion revascularization can sometimes be challenging. Herein, we describe a novel method to facilitate "tip-in". After retrograde lesion crossing, the retrograde wire is advanced in a stepwise fashion into the antegrade guide catheter, the guide extension catheter and finally into the antegrade microcatheter. The use of a small lumen guide extension catheter to facilitate "tip-in" works by decreasing the area of operation, hence maximizing the chances of the wire and microcatheter meeting in the same plane. Overall, this newly described "double tip-in" technique can increase procedural success and decrease procedural time.

Slender Bi-Radial Ping-Pong Technique for Complete Revascularisation of Concomitant CTO and Non-LM Bifurcation Lesions: A Report of Two Cases

The "ping-pong" technique entails the use of two different guide catheters to alternately engage the same coronary artery during percutaneous coronary intervention (PCI). Bi-arterial vascular access for dual injection is the standard of care in contemporary chronic total occlusion (CTO) PCI. Two-stent bifurcation PCI strategies require a minimum of 6 French (F) guide catheter. In this report, we describe two cases where dual access initially made for CTO PCI was leveraged for subsequent bifurcation PCI in the same setting, by means of two 5F Judkin's Left (JL) guides in a transradial "slender" double-guiding catheter "ping-pong" strategy. In both cases, two 5F JL guides were initially navigated via bi-radial access for antegrade and retrograde injection from left anterior descending artery (LAD) and right coronary artery (RCA) respectively, to facilitate PCI to CTO of LAD. After successful crossing of the LAD CTO lesions, we took advantage of the two 5F JL guides already present via this dual access created for CTO PCI, to adopt the novel use of the "ping-pong" guide technique in order to perform bifurcation PCI by two-stent strategy. In the first case, PCI of the left circumflex (LCx)/obtuse marginal (OM) bifurcation was performed by the DK-Culotte technique with two JL 5F guides used to alternately engage the left main (LM) coronary artery, with wiring and passage of equipment to the LCx and OM done via separate "ping-pong" guides engaging the LM. In the second case, LAD/Diagonal bifurcation PCI was performed by T and protrusion (TAP) technique in a similar slender fashion via "ping-pong" guides. This approach has limited indications. As described in our case report, the CTO lesion was relatively less complex, the LM was not diseased and importantly, narrow radial artery diameters of the patients precluded the use of larger 6F guide transradially. Advantages of this ping-pong technique in bifurcation PCI include the avoidance of wire wrap, accommodation and easy delivery of multiple hardware, and the non-necessity of changing multiple guides, thus reducing radial artery spasm, particularity among those with narrower radial artery diameters.

DES Strut Thickness and Clinical Outcomes After CTO Recanalization: Insights From LATAM CTO Registry

BACKGROUND

Ultra-thin strut drug-eluting stent (UTS-DES) may improve outcomes after percutaneous coronary intervention (PCI) but have received limited study in chronic total occlusion (CTO) PCI.

AIMS

To compare of 1-year incidence of major adverse cardiac events (MACE) between patients who underwent CTO PCI with ultrathin (≤ 75 μm) versus thin (>75 μm) strut DES in the LATAM CTO registry.

METHODS

Patients were considered for inclusion only if successful CTO PCI was performed and when only one type of stent strut thickness (ultrathin or thin) was used. A propensity score matching (PSM) was computed to produce similar groups in relation to clinical and procedural characteristics.

RESULTS

Between January 2015 and January 2020, 2092 patients underwent CTO PCI, of whom 1466 were included in the present analysis (475 in the ultra-thin and 991 in the thin strut DES). In unadjusted analysis the UTS-DES group had lower rate of MACE (HR: 0.63 95 % CI 0.42 to 0.94, p = 0.04) and repeat revascularizations (HR: 0.50 95 % CI 0.31 to 0.81, p = 0.02) at 1-year follow-up. After adjustment for confounding factors in a Cox regression model there was no difference in 1-year incidence of MACE between groups (HR: 1.15 95 % CI 0.41 to 2.97, p = 0.85). On PSM of 686 patients (343 in each group) the 1-year incidence of MACE (HR 0.68 95 % CI 0.37-1.23; P = 0.22) and individual components of MACE did not differ between groups.

CONCLUSIONS

One-year clinical outcomes after CTO PCI were similar with ultrathin and thin strut DES.

A LASSO-derived developing and validating risk model for chronic total occlusion in Asian population before coronary angiography

Background

Despite several previous studies that have explored the predictors of high morbidity in coronary artery disease (CAD) and developed nomograms for CAD patients prior to coronary angiography (CAG), there is a lack of models available to predict chronic total occlusion (CTO). The aim of this study is to develop a risk model and a nomogram for predicting the probability of CTO prior to CAG.

Methods

The study included 1,105 patients with CAG-diagnosed CTO in the derivation cohort and 368 patients in the validation cohort. Clinical demographics, echocardiography results, and laboratory indexes were analyzed using statistical difference tests. Independent risk factors affecting the CTO indication were selected using least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis. A nomogram was built and validated based on these independent indicators. The performance of the nomogram was evaluated using area under the curve (AUC), calibration curve, and decision curve analysis (DCA).

Results

LASSO and multivariate logistic regression analysis revealed that 6 variables, including sex (male), lymphocyte percentage (LYM%), ejection fraction (EF), myoglobin (Mb), non-high-density lipoprotein cholesterol (non-HDL), and N-terminal pro-B-type natriuretic peptide (NT-proBNP), were independent predictors of CTO. The nomogram constructed based on these variables showed good discrimination (C index of 0.744) and external validation (C index of 0.729). The calibration curves and DCA demonstrated high reliability and precision for this clinical prediction model.

Conclusions

The nomogram based on sex (male), LYM%, EF, Mb, non-HDL, and NT-proBNP could be used to predict CTO in CAD patients, enhancing the ability to predict their prognosis in clinical practice. Further research is needed to validate the efficacy of the nomogram in other populations.

Dilemmas in cardiology: when to recanalize a chronic total occlusion

The decision whether or not to recanalize a chronic total occlusion (CTO) of a coronary artery is truly a dilemma for the cardiologist. The procedure is in fact complex, with a non-negligible rate of complications and with a probability of success lower than that of non-obstructive lesions. The analysis of the data available in the literature, with the significant discrepancy between the results of the randomized studies and the observational studies, does not currently allow conclusive statements on the role of the percutaneous coronary interventions in CTO. It is therefore essential to incorporate clinical, anatomical and procedural elements into the decision-making algorithm. While awaiting new randomized clinical trials of greater dimensions and better methodology, a careful selection of patients is certainly essential, limiting the procedure to those who are symptomatic or who have a high ischaemic burden and excluding those who have no evidence of vitality, without which it is not legitimate to expect any benefit from the intervention. Finally, the presence of the collateral circulation does not in itself appear to be an element that should have a significant decision-making role.

Evaluation of right atrial function by two-dimensional echocardiography and strain imaging in patients with RCA CTO recanalization

OBJECTIVES

The right heart is mainly supplied with blood by the right coronary artery (RCA). The impact of RCA chronic total occlusion (CTO) on the function of the right heart [right atrium (RA) and ventricle (RV)] and whether successful recanalization of a RCA CTO improves the function of the right heart is not clearly understood yet. We aimed to evaluate right atrial function after recanalization of the RCA using transthoracic echocardiography with additional strain imaging.

METHODS AND RESULTS

Fifty-five patients undergoing RCA CTO recanalization at the University Medical Center of Mainz were included in the study. Right atrial strain was assessed before and 6 months after successful CTO revascularization. The median age of the total collective was 66 (50-90) years. We did not find difference in our analysis of RA Volume (p 0.086), RA area (p 0.093), RA major dimension (p 0.32) and RA minor dimension (p 0.139) at baseline and follow-up. Mean RA reservoir strain at baseline was 30.9% (21.1-43.0) vs. 33.4% (20.7-47.7) at follow up (p < 0.001). Mean RA conduit strain was - 17.5% (- 10.7-(- 29.7)) at baseline vs. - 18.2% (- 9.6-(- 31.7)) at follow-up (p = 0.346). Mean RA contraction strain was - 12.9% (- 8.0- (- 21.3)) at baseline vs. - 15.5% (- 8.7-(- 26.6)) at follow-up (p < 0.001).

CONCLUSION

Right atrial function was altered in patients with RCA CTO. Successful revascularisation of an RCA CTO improved RA function assessed by strain imaging at follow-up.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pericardial tamponade after chronic total occlusion revascularization: a case report and literature review

Pericardial tamponade is a complication of percutaneous coronary intervention (PCI) with extremely high mortality. The rupture of coronary artery causes hypotension and shock, eventually resulting in death due to pericardial tamponade. Because of the complex operation in revascularization of chronic total occlusion (CTO-PCI) lesion, the incidence of pericardial tamponade increases. Usually, we use coronary angiogram to identify the rupture of coronary artery after PCI by the contrast agent. We presented a 67-year-old woman with pericardial tamponade after CTO revascularization. She had chest pain and out of breath for nearly two years. The coronary angiogram showed three branch lesion and CTO lesion of the right coronary artery (RCA). After revascularization of the RCA CTO lesion, the pericardial effusion and low blood pressure occurred, but we didn't find the leak of contrast agents during the final angiography. Then the patient was transferred to cardiac surgery department for emergency thoracotomy. They found the hematoma on the surface of the RCA and finally discharged without any symptoms. Our case approved: (I) there was still the possibility of coronary artery rupture even the coronary angiogram showed no contrast agent leakage from the coronary artery after PCI; (II) the combined use of IVUS and coronary angiogram may improve the accuracy and safety of CTO revascularization procedure.

Real world perspective of coronary chronic total occlusion in third world countries: A tertiary care centre study from northern India

OBJECTIVES

The aim of this study is to determine the prevalence, clinical characteristics, angiographic profile and predictors of outcome for percutaneous coronary interventions (PCI) of coronary chronic total occlusions (CTO) in a tertiary referral centre of north India.

BACKGROUND

There is no data on the prevalence and very few reports on clinical characteristics, angiographic profile and outcome of PCI in CTO from India.

METHODS

Retrospective analysis was done for the data of 12,020 patients undergoing coronary angiography (CAG) between January 2018 to January 2019 at our centre. Detailed baseline clinical, angiographic and revascularization data was collected. Outcome of CTO PCI was also noted. All baseline parameters were analysed for predicting the outcome of CTO PCI.

RESULTS

CTO was identified in 16.3% (1968) patients undergoing CAG and in 24.4% of patients with hemodynamically significant CAD. CTO was predominantly found in LAD (48%) followed by RCA (42.9%) and LCx (25.3%) arterial distribution. Mean JCTO score was 1.93 ± 0.7. PCI as a management strategy was adopted in 456 of 1968 patients (23.1%) and was successful in 340 of 456 (74.6%) of patients. Almost all CTO PCI were attempted by an antegrade approach only. Increasing age, male sex, CTO in LCx arterial distribution and higher J CTO score were associated with poorer outcome in CTO PCI.

CONCLUSIONS

CTO's are commonly encountered during CAG procedures. In patients undergoing CTO PCI, a fair success rate can be achieved in a high volume experienced centre.

Procedures for chronic total occlusion: when are they recommended and when not

Coronary chronic total occlusion (CTO) produces an important clinical problem, often treated with medical therapy or coronary artery bypass grafting. Recent clinical studies, both registries and randomized trials, demonstrated that percutaneous coronary interventions (PCI), could provide a valid therapeutic option. Nonetheless, significant reduction in all-cause mortality, cardiac mortality, myocardial infarction, MACE, and MACCE has not been demonstrated in the subgroups analysis of randomized trials. These analyses suggest that PCI for CTO should be reserved for patients with angina or with large areas of the myocardium with reversible ischaemia. Large randomized studies should search for a personalized approach, considering the risks and complexity of PCI in CTO, which should mainly consider the extension of the ischaemia and the viability of the myocardium.

What is the cause of hypotension? A rare complication of percutaneous coronary intervention of a chronic total occlusion: a case report

Background

In the last few years, complex techniques and advanced equipment became available to treat chronically occluded coronary arteries. Such procedures portend a series of possible complications that operators should be ready to quickly recognize and deal with.

Case summary

A 75-year-old lady with uncontrolled stable angina underwent percutaneous treatment of a chronically occluded right coronary artery. After balloon angioplasty and stenting, she developed a severe hypotension, refractory to fluid resuscitation and vasopressors. Computerized tomography scan demonstrated an intramural haematoma (IMH) of the right atrioventricular groove resulting in life-threatening pseudotamponade (or dry tamponade), as further confirmed by cardiac magnetic resonance imaging (MRI). The decision was for conservative management and haemodynamic support by intra-aortic balloon pump. Clinically, the patient improved and was discharged a few days later. Follow-up MRI confirmed resolution of the IMH.

Discussion

Severe hypotension during percutaneous treatment of chronically occluded coronary arteries may be related to various causes. Differential diagnosis is thus important in this setting and should include IMH, a rare but potentially fatal complication as it may cause compression of cardiac chambers and lead to pseudotamponade. A high index of suspicion is required to diagnose IMH but there are no clear guidelines for management of such cases.

Successful treatment of complex coronary chronic total occlusions improves midterm outcomes

BACKGROUND

Data regarding outcomes of percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) is still limited. Our aim was to evaluate clinical outcomes in patients after successful CTO PCI when compared to patients with failed PCI.

METHODS

The cohort study enrolled 145 eligible patients with attempted PCI of CTO. Detailed baseline clinical and procedural data, and in-hospital complications were analyzed. The primary end point was occurrence of major adverse cardiac events (MACE).

RESULTS

Median follow-up was 11.49±2.01 months. Successful revascularization was associated with a significantly lower 1-year MACE compared to failed revascularization [hazard ratio (HR): 0.026; 95% confidence interval (CI): 0.004-0.176; P=0.0002]. A J-CTO score of ≥3 was associated with a significantly higher 1-year MACE compared with a J-CTO score of <3 in patients undergoing PCI (HR: 4.819; 95% CI: 1.463-15.870; P=0.0097). Moreover, in patients with a J-CTO score ≥3, success of CTO PCI was associated with significantly lower risk of 1-year MACE than failure of CTO revascularization (HR: 0.114; 95% CI: 0.023-0.569; P=0.0081). Multivariate analysis identified the J-CTO score (HR: 2.10; 95% CI: 1.09-4.04; P=0.026) as a positive predictor, and the success of CTO PCI (HR: 0.17; 95% CI: 0.05-0.59; P=0.005) as a negative significant independent predictor of MACEs.

CONCLUSIONS

Among patients with CTOs, high J-CTO score was independently associated with worse clinical outcomes. Furthermore, successful PCI was associated with a lower risk of midterm MACE compared with failed revascularization of CTOs.

Integrated application of antegrade and retrograde recanalization for femoral-popliteal artery chronic total occlusions: outcomes compared with antegrade recanalization

Background

To investigate the efficacy of retrograde recanalization for chronic total occlusion (CTO) of femoral-popliteal artery in patients with peripheral arterial disease.

Methods

In this single-center retrospective study, all patients who had undergone endovascular recanalization for femoral-popliteal CTOs at our center from June 2011 to October 2014 were included. Patients' demographics, immediate and follow-up outcomes were analyzed.

Results

A total of 205 patients with 238 CTOs were enrolled. In total, successful recanalization was achieved in 228 CTOs (95.8%). The antegrade procedure was successful in 196 CTOs. The retrograde procedure was successfully performed in 32 CTOs after failed antegrade procedure. Ankle-brachial index increased from 0.48±0.18 to 0.79±0.16 in antegrade group vs. 0.41±0.13 to 0.76±0.13 in retrograde group (P=0.438). Pulse score increased from 0.48±0.50 to 2.30±0.76 in antegrade group vs. 0.48±0.51 to 2.30±0.79 in retrograde group (P=0.771). At 12 and 24 months, primary patency rate was 86.2% (169/196) and 51.5% (101/196) in the antegrade group, and 75.0% (24/32) and 43.8% (14/32) in the retrograde group, respectively (P=0.346). Kaplan-Meier analysis showed limb salvage rates of 85.7% in the antegrade group vs. 78.1% in the retrograde group (P=0.198).

Conclusions

Retrograde recanalization is effective for CTO of femoral-popliteal artery after the failure of an antegrade procedure; immediate outcomes and mid-term patency and limb salvage rate are comparable with that of antegrade procedure.

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

Background

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

Methods

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

Results

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

Conclusions

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

Coronary Chronic Total Occlusion (CTO): A Review

Coronary artery chronic total occlusions (CTO) are frequently encountered during coronary angiography; however percutaneous recanalization has historically been technically challenging and an important determinant for referral to coronary artery bypass surgery or for medical therapy alone. Recent advances in interventional equipment and innovative approaches to crossing CTO have significantly increased the success rate of percutaneous treatment. Although there is only one relevant randomized control trial (RCT) performed to date, several large, nonrandomized studies have consistently reported improvement in clinical outcomes, including improved survival and relief of angina, when successful percutaneous treatment of CTO was compared with unsuccessful revascularization. These positive observational results have encouraged the initiation of several RCTs which will provide more robust evidence on clinical outcomes of CTO-PCI compared with guideline-directed medical therapy (GDMT) alone.

"Spiral stenting"-creating a subintimal neo-luminal helix around a massively calcified ostial chronic total occlusion of the right coronary artery in a patient with recurrent ventricular tachycardia

This case report describes a successful percutaneous coronary intervention (PCI) of a severely calcified aorto-ostial chronic total occlusion (CTO) of the right coronary artery (RCA). The lesion was treated by a retrograde approach implementing long spiral subintimal wire tracking and final coronary stenting creating a subintimal neo-luminal helix around the natively occluded RCA. After 6 months of follow-up valuable angiographic results were proven.

[Subintimal recanalization. Indications, technique and results]

CLINICAL/METHODICAL ISSUE

This article gives an overview of the current importance of so-called subintimal recanalization in the lower extremities.

STANDARD RADIOLOGICAL METHODS

The primary technical goal of endovascular interventions in the lower extremities is the endoluminal restoration of blood circulation from the iliac arteries into the feet.

METHODICAL INNOVATIONS

If endoluminal recanalization of e.g. high-grade flow-relevant stenoses or chronic total occlusion (CTO) is technically not possible, subintimal recanalization is a promising option and the only remaining minimally invasive alternative. During subintimal recanalization a channel is intentionally generated in the vessel wall (dissection) in order to bypass e. g. a chronic vascular occlusion over as short a distance as possible.

PERFORMANCE

The technical success rate for subintimal recanalization of CTO of the lower extremities is 65-100 %. Technical failure occurs in approximately 25 % using the catheter and wire technique and is caused in most cases by difficulties in reaching the true lumen after the subintimal passage (the so-called re-entry).

ACHIEVEMENTS

Compared to conventional subintimal recanalization, in recent years so-called re-entry devices have expanded the technical possibilities and depending on the medical experience and training level of the physician, provide an improvement in the technical success rate, a lower complication rate, a reduction of fluoroscopy time and the amount of necessary contrast medium but also result in higher costs.

PRACTICAL RECOMMENDATIONS

Subintimal recanalization, whether carried out conventionally with a catheter and wire or using re-entry devices, of high-grade stenoses or CTO in the lower extremities provides a high technical success rate but requires an experienced and trained physician who is capable of operating the elaborate materials and mastering any possible complications.

Bioresorbable vascular scaffold (BVS) for in-stent chronic total occlusion: Antegrade recanalization and IVUS-guided BVS implantation by radial access

The completely absorbable stents represent one of the latest innovations in the field of interventional cardiology, prospecting the possibility of "vascular repair". In the published trials (ABSORB Cohort A and B, ABSORB EXTEND, and ABSORB II, III and IV) chronic total occlusions (CTOs) were considered an exclusion criteria. More recently the CTO-ABSORB pilot study demonstrated the safety and feasibility of bioresorbable vascular scaffold (BVS) use in case of CTO recanalization. We present the first case, to our knowledge, of in-stent occlusion successfully treated with an everolimus-eluting BVS and discuss its potential advantages in such kind of lesions.

The open retrograde approach as an alternative for failed percutaneous access for difficult below the knee chronic total occlusions-A case series

Retrograde puncture via patent pedal vessels can be attempted in failed antegrade approach for infrapopliteal long chronic total occlusion. However in cases where the pedal vessels are unable to be visualized via duplex ultrasonography or fluoroscopy an open approach offers an additional option to a vascular surgeon for successful recanalization. Our case report highlights 3 cases where successful hybrid open retrograde approach was able to achieve recanalization of long chronic total occlusion.

Presentation of cases

The three cases in our series presented with critical limb ischaemia. All three cases had undergone duplex imaging of the affected arterial system. As the antegrade approach to cross the lesion failed a retrograde approach was attempted in all 3 cases. However when the usual modality of retrograde puncture via the use of ultrasound or fluoroscopy failed we proceeded with an open approach.

Discussion

Retrograde approach usually offers a better chance of successfully crossing a chronic total occlusion lesion. However puncturing a distal vessel successfully and traversing a catheter or guidewire across proves to be a challenge. An open approach offers an additional pathway for puncturing the target vessel when duplex imaging or fluoroscopic guidance fails.

Conclusion

Open approach is usually attempted as a last resort by many endovascular surgeons. However procedural time, contrast and radiation usage could have been cut short in cases where the distal target vessels pose a technical challenge for approach via a percutaneous method.

Comparison of magnetic wire navigation with the conventional wire technique for percutaneous coronary intervention of chronic total occlusions: a randomised, controlled study

Wire crossing of a chronic total coronary occlusion (CTO) is time consuming and limited by the amount of contrast agent and time of radiation exposure. Magnetic wire navigation (MWN) might accelerate wire crossing by maintaining a coaxial vessel orientation. This study compares MWN with the conventional approach for recanalization of CTOs. Forty symptomatic patients with CTO were randomised to MWN (n = 20) or conventional approach (n = 20) for antegrade crossing of the occlusion. In the intention-to-treat analysis, MWN showed a shorter crossing time (412 versus 1131 s; p = 0.001), and, consequently, lower usage of contrast agent (primary endpoint 42 versus 116 ml; p = 0.01), and lower radiation exposure (dose-area product: 29 versus 80 Gy*cm(2); p = 0.002) during wire crossing compared to the conventional approach. Accordingly, in the per-protocol analysis, the wire-crossing rate was, in trend, higher using the conventional approach (17 of 31) compared to MWN (9 of 28; p = 0.08). The use of MWN for revascularisation of CTOs is feasible and reduces crossing time, use of contrast agent, and radiation exposure. However, due to a broader selection of wires, the conventional approach enables wire crossing in cases failed by MWN and seems to be the more successful choice.

Chronic total improvement in ventricular function and survival

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