Chapter 20 - Thrombus debulking in revascularization of atherosclerotic chronic total occlusions

Abstract

Chronic total occlusion (CTO) is commonly found in patients with coronary and peripheral atherosclerotic disease. The major histopathologic constituents of these plaques include fibrotic tissue, calcium deposits, and organized thrombus. Coronary CTOs cause myocardial ischemia and angina pectoris while peripheral CTOs cause limb ischemia and claudication. CTO serves as the most powerful predictor of referral for coronary and peripheral vascular bypass surgery, respectively. The contemporary, first-in-line management option for symptomatic patients with CTO is percutaneous intravascular interventions; however, these interventions commonly encounter formidable technical challenges due to the complexity of the lesions. Percutaneous interventions displace plaque with a standard balloon while plaque debulking by dedicated devices removes tissue to modify the plaque morphology. Accordingly, debulking improves the delivery and deployment of stents and decreases restenosis rates. The combination of various debulking technologies with adjunct stenting can achieve a 70%–90% success rate in CTOs; however, this rate is still comparatively lower than in non-CTO stenoses. Intriguingly, the presence of a thrombus within a CTO serves as a strong predictor of procedural success.