A thirty-four-year-old chronic total occlusion successfully treated by percutaneous coronary intervention

Abstract

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) represents a major challenge for interventional cardiology. CTOs are identified in up to 30% of patients with significant coronary disease on angiography and represent only 10–15% of cases treated by PCI, with the majority of patients being treated medically or referred for surgery [ [1] Stone G.W. Kandzary D.E. Mehran R. et al. Percutaneous recanalization of chronically occluded coronary artery: a consensus document: part I. Circulation. 2005; 112: 2364-2372 Crossref PubMed Scopus (456) Google Scholar ]. This may be explained considering the lower procedural success achieved in these lesions in comparison with non-occluded lesions [ [2] Stone G.W. Rutherford B.D. Mc-Conahay D.R. et al. Procedure outcome of angioplasty for total coronary occlusion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol. 1990; 15: 849-856 Abstract Full Text PDF PubMed Scopus (212) Google Scholar ]. The major reason for procedural failure is represented by the inability to cross the occlusion, with a guidewire or a balloon [ 2 Stone G.W. Rutherford B.D. Mc-Conahay D.R. et al. Procedure outcome of angioplasty for total coronary occlusion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol. 1990; 15: 849-856 Abstract Full Text PDF PubMed Scopus (212) Google Scholar , 3 Stone G.W. Colombo A. Teirstein P.S. et al. Percutaneous recanalization of chronically occluded coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc Interv. 2005; 66: 217-236 Crossref PubMed Scopus (127) Google Scholar ]. A number of predictors of procedural success have been reported in the literature. It is accepted that a blunt occlusion stump, heavy calcification, proximity to a side branch, presence of bridging collaterals and longer occlusions, all impact unfavorably on the likelihood of procedural success [ [4] Kinoshita I. Katoh O. Nariyama J. et al. Coronary angioplasty of chronic total occlusions with bridging collateral vessels: immediate and follow-up outcome from a large single-center experience. J Am Coll Cardiol. 1995; 26: 409-415 Abstract Full Text PDF PubMed Scopus (154) Google Scholar ]. In addiction previous studies have reported that long occlusion duration may also be associated with procedural failure [ 5 Kereiakes D.J. Selmon M.R. McAuley D.B. et al. Angioplasty in total coronary artery occlusion: experience in 76 consecutive patients. J Am Coll Cardiol. 1985; 6: 526-533 Abstract Full Text PDF PubMed Scopus (140) Google Scholar , 6 Melchoir J.P. Meire B. Urban P. et al. Percutaneous transluminal coronary angioplasty for chronic total occlusion. Am J Cardiol. 1987; 59: 535-538 Abstract Full Text PDF PubMed Scopus (149) Google Scholar ]. It was supposed that this issue was related to the increase lesion organization with deposition of fibrous tissue and severe calcifications, which occur in the course of time. Furthermore aging of occlusion may determine a change in plaque composition with an increase of frequency and severity of plaque calcification [ [7] Suzuki T. Hosokawa H. Yokoya K. et al. Time-dependent morphologic characteristics in angiographic chronic total coronary occlusions. Am J Cardiol. 2001; 88: 167-169 Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar ]. A study of Barlis et al. underlined how indetermination of occlusion duration (IOD) could play a role in prediction of procedural failure and cardiac adverse events [ [8] Barlis P. Kaplan S. Dimopoulos K. et al. An indeterminate occlusion duration predicts procedural failure in the recanalization of coronary chronic total occlusions. Catheter Cardiovasc Interv. 2008; 71: 621-628 Crossref PubMed Scopus (23) Google Scholar ]. However Tomasello et al. have recently showed that IOD and long duration of CTO do not affect procedural and clinical outcome of patients who underwent CTO PCI [ [9] Tomasello S.D. Costanzo L. Campisano M.B. et al. J Interv Cardiol. 2011; 24: 223-231 Crossref PubMed Scopus (14) Google Scholar ].