Abstract
Successful revascularisation of chronic total occlusions (CTOs) remains one of the greatest challenges in the era of contemporary percutaneous coronary intervention (PCI). Such lesions are encountered with increasing frequency in current clinical practice. A predictable increase in the future burden of CTO management can be anticipated given the ageing population, increased rates of renal failure, graft failure and diabetes mellitus. Given recent advances and developments in CTO PCI management, successful recanalisation can be anticipated in the majority of procedures undertaken at high-volume centres when performed by expert operators. Despite advances in device technology, the management of resistant, calcific lesions remains one of the greatest challenges in successful CTO intervention. Established techniques to modify calcific lesions include the use of high-pressure non-compliant balloon dilation, cutting-balloons, anchor balloons and high speed rotational atherectomy (HSRA). Novel approaches have proven to be safe and technically feasible where standard approaches have failed. A step-wise progression of strategies is demonstrated, from well-recognised techniques to techniques that should only be considered when standard manoeuvres have proven unsuccessful. These methods will be described in the setting of clinical examples and include use of very high-pressure non-compliant balloon dilation, intentional balloon rupture with vessel dissection or balloon assisted micro-dissection (BAM), excimer coronary laser atherectomy (ECLA) and use of HSRA in various ‘offlabel’ settings.
Highlights
In the contemporary era of interventional cardiology, chronic total occlusions (CTOs) are encountered with increasing frequency
We have demonstrated successful use of high speed rotational atherectomy (HSRA) through calcific diseased segments in the sub-intimal space
An increasing burden of resistant, calcific coronary lesions can be anticipated by the interventional cardiologist in future clinical practice
Summary
In the contemporary era of interventional cardiology, chronic total occlusions (CTOs) are encountered with increasing frequency. Advances in antegrade or retrograde wiring with dissection and re-entry techniques have afforded the opportunity of high procedural success rates with limited complications Such techniques are facilitated by novel equipment including the CrossBossTM and StingrayTM (Boston Scientific, Natick, MA) devices. In cases where crossing the proximal cap is found to be extremely challenging or impossible with standard techniques, deliberate bypassing of the cap by entering the subintimal space and performing antegrade or retrograde dissection, may facilitate a successful outcome. This is known as controlled antegrade and retrograde sub-intimal tracking (CART) [10].
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