Approach For Chronic Total Occlusion Research Articles

Retrograde Coronary Chronic Total Occlusion Intervention (JR-CTO) Score: From the Japanese CTO-PCI Expert Registry

BackgroundDespite the effectiveness of the retrograde approach for chronic total occlusion (CTO) lesions, there are no standardized tools to predict the success of retrograde percutaneous coronary intervention (PCI). ObjectivesThe aim of this study was to develop a prediction tool to identify CTO lesions that will achieve successful retrograde PCI. MethodsThis study evaluated data from 2,374 patients who underwent primary retrograde CTO-PCI and were enrolled in the Japanese CTO-PCI Expert Registry between January 2016 and December 2022 (NCT01889459). All observations were randomly assigned to the derivation and validation cohorts at a 2:1 ratio. The prediction score for guidewire failure in retrograde CTO-PCI was determined by assigning 1 point for each factor and summing all accrued points. ResultsThe JR-CTO score (moderate–severe calcification, tortuosity, Werner collateral connection grade ≤1, and nonseptal collateral channel) demonstrated a C-statistic for guidewire failure of 0.72 (95% CI: 0.67-0.76) and 0.71 (95% CI: 0.64-0.77) in the derivation and validation cohorts, respectively. Patients with lower scores had higher guidewire and technical success rates and decreased guidewire crossing time and procedural time (P < 0.01). ConclusionsThe JR-CTO (Japanese Retrograde Chronic Total Occlusion) score, a simple 4-item score that predicts successful guidewire crossing in patients undergoing retrograde CTO-PCI, has the potential to support clinical decision-making for the retrograde approach.

Outcomes of retrograde approach for chronic total occlusions by guidewire location.

Connecting the antegrade wire (AW) and the retrograde wire (RW) is a goal of chronic total occlusion (CTO) treatment, but angiographic guidewire location is sometimes misleading. The aim of this study was to evaluate the association between intravascular ultrasound (IVUS)-defined AW and RW position and procedural outcomes when treating CTO lesions using the retrograde approach. Overall, 191 CTO lesions treated using an IVUS-guided retrograde approach at three centres in Japan, China, and the USA were included. When the AW and RW angiographically overlapped, four wire positions were seen on IVUS: (i) AW within the plaque (AW-intraplaque) and RW-intraplaque in 34%; (ii) AW-intraplaque and RW in the subintimal space (RW-subintima) in 28%; (iii) AW-subintima and RW-subintima in 22%; or (iv) AW-subintima and RW-intraplaque in 16%. The procedure succeeded without repositioning the wire in 89% of AW-intraplaque/RW-intraplaque, 61% of AW-intraplaque/RW-subintima and 57% of AW-subintima/RW-subintima, but only one (3%) AW-subintima/RW-intraplaque. Lesion and procedure complexity and failure/complications were greatest in AW-subintima/RW-intraplaque. IVUS-identified vascular compartment concordance versus IVUS-identified vascular compartment mismatch leads to higher success rates irrespective of intraplaque or subintimal passage. AW-subintima/RW-intraplaque was associated with the most complex CTO morphology and procedure, and repositioning the wire was almost always necessary. Visual summary. When the antegrade wire is in the subintimal space and the retrograde wire is in the intraplaque, re-wiring is almost always necessary.

Percutaneous Reconstruction Techniques: Popliteal Artery Approach for Chronic Total Occlusion of Superficial Femoral and Iliac Arteries

Percutaneous Reconstruction Techniques: Popliteal Artery Approach for Chronic Total Occlusion of Superficial Femoral and Iliac Arteries

TCT-103 Wire Location by IVUS Strongly Predicts Procedural Success in the Retrograde Approach for Chronic Total Occlusions

During retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI), antegrade wire (AW) and retrograde wire (RW) locations are important. A total of 182 CTO lesions were treated with an intravascular ultrasound (IVUS)–guided retrograde approach at 3 centers in Japan, China,

TCT-373 Safety and Efficacy of Transradial versus Transfemoral Approach for Chronic Total Occlusion: A Meta-analysis

Chronic total occlusion (CTO) lesions are found in 10-25% of patients with percutaneous coronary intervention (PCI) for ST elevation myocardial infarction. Previous studies comparing outcomes of transradial (TR) versus transfemoral (TF) approach for CTO lesions have shown conflicting results. This

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Although several new techniques have been introduced for CTO such as the retrograde approach, the fundamental question of what type of guidewire is the most appropriate as a primary guidewire in the antegrade approach has not been answered.The G-FORCE study was designed as a prospective multicenter randomized controlled trial to determine the efficient primary guidewire in antegrade approach for chronic total occlusion (CTO). The first guidewire was randomly assigned to a regular size distal tip group (0.014 in. size) or tapered tip group (0.010 in. or less). The primary endpoint was defined as successful lesion penetration by the first guidewire into distal true lumen. This study was registered at ClinicalTrials.gov with identifier NCT00987610.A total of 260 patients were enrolled, with an average age of 66 ± 11 years and 16% were female. The average J-CTO score was 1.8 ± 1.1. The primary endpoint was achieved in 38% and 32% of patients using tapered and regular distal tip guidewires, respectively (P = 0.80). The final PCI success rate was 81% vs. 85%, respectively (P = 0.57). Easy CTO lesions with a J-CTO score = 0 exhibited a primary endpoint significantly different between tapered and regular distal tip primary guidewires (79% vs. 40%; P = 0.046). Guidewire distal coating or distal tip load did not relate with primary guidewire success rate.Tapered and regular distal tip guidewires are equivalent as a first choice for CTO. Tapered guidewires are superior for CTO lesions with a J-CTO score = 0.

TCTAP C-077 Successful "Rendezvous in Coronary" Technique with the Retrograde Approach for Chronic Total Occlusion After Anterograde Coronary Perforation

### Patient Initials or Identifier Number 1305810 ### Relevant Clinical History and Physical Exam 55 years old male patient with history of hypertension, had exertional chest pain developing recently. He had undergone PCI (on LAD and LCx) in 2007, So he went through Echocardiography and

TCTAP C-242 Successful Trans-collateral Approach for Chronic Total Occlusion of the Superficial Femoral Artery Using a Side-hole Sheath

TCTAP C-242 Successful Trans-collateral Approach for Chronic Total Occlusion of the Superficial Femoral Artery Using a Side-hole Sheath

A pitfall in selecting promising septal collateral channels in percutaneous coronary intervention with a retrograde approach

Introduction: In percutaneous coronary intervention (PCI) with a retrograde approach, successful guide wire passage through the collateral channels is indispensable. However, success of the procedure depends on the quality of collateral channels, and vascular tortuosity is one of the most common obstacles for successful guidewire passage. Case Presentation: Herein, we present a case of PCI with retrograde approach for chronic total occlusion at the ostium of the left anterior descending coronary artery. A highly tortuous morphology of the right posterior descending artery (PDA) and septal channels bifurcating from the right PDA with marked angulations were recognized in angiographic images from multiple directions. We could advance a guidewire to the optimal route of the septal collateral channel with guidance provided by these images and successfully completed all PCI procedures. Conclusions: To pass a guidewire through collateral arteries in PCI with a retrograde approach, careful inspection of angiographic images for thoroughly understanding the optimal route through the collateral vasculature is of great significance.

Efficient distal tip size of primary guidewire for antegrade percutaneous coronary intervention in chronic total occlusion: The G-FORCE study

BackgroundAlthough several new techniques have been introduced for CTO such as the retrograde approach, the fundamental question of what type of guidewire is the most appropriate as a primary guidewire in the antegrade approach has not been answered. MethodsThe G-FORCE study was designed as a prospective multicenter randomized controlled trial to determine the efficient primary guidewire in antegrade approach for chronic total occlusion (CTO). The first guidewire was randomly assigned to a regular size distal tip group (0.014in. size) or tapered tip group (0.010in. or less). The primary endpoint was defined as successful lesion penetration by the first guidewire into distal true lumen. This study was registered at ClinicalTrials.gov with identifier NCT00987610. ResultsA total of 260 patients were enrolled, with an average age of 66±11years and 16% were female. The average J-CTO score was 1.8±1.1. The primary endpoint was achieved in 38% and 32% of patients using tapered and regular distal tip guidewires, respectively (P=0.80). The final PCI success rate was 81% vs. 85%, respectively (P=0.57). Easy CTO lesions with a J-CTO score=0 exhibited a primary endpoint significantly different between tapered and regular distal tip primary guidewires (79% vs. 40%; P=0.046). Guidewire distal coating or distal tip load did not relate with primary guidewire success rate. ConclusionTapered and regular distal tip guidewires are equivalent as a first choice for CTO. Tapered guidewires are superior for CTO lesions with a J-CTO score=0.

Treatment of chronic total occlusions in native coronary arteries by drug-coated balloons without stenting - A feasibility and safety study

BackgroundChronic total occlusions remain one of the biggest challenges for interventional cardiologists and the high risk of restenosis and stent thrombosis is still a major problem. Drug-coated balloons showed favorable results for the treatment of in-stent restenosis and other lesion types. The aim of this study was to evaluate the feasibility and outcome of a drug-coated balloon only approach for chronic total occlusion. MethodsWe included 34 patients with a native chronic total occlusion treated only by drug-coated balloons. A visual residual stenosis of 30% or less without major dissection was considered a satisfactory percutaneous intervention result according to the German Consensus Group recommendations for drug-coated balloon use. We collected clinical and procedural data. Angiograms were conducted during the procedure and at follow-up. Quantitative coronary analysis was performed and mean and minimal lumen diameter and late luminal changes were assessed. ResultsThe recanalization was considered satisfactory in 79.4% (n=27). Restenosis occurred in 11.8% (n=4) and reocclusion in 5.9% (n=2). Out of the 27 patients with a satisfactory initial result, 3.7% (n=1) had reocclusion and 3.7% (n=1) had restenosis. In the subgroup without satisfactory result (n=7), restenosis occurred in 3 patients (42.9%) and reocclusion in 1 patient (14.3%). A luminal increase was found in 67.6% (n=23) and mean late luminal gain was 0.11±0.49mm. Angina class improved significantly (p<0.001). There was no death or myocardial infarction. ConclusionsDrug-coated balloon angioplasty without stenting is a feasible and well-tolerated treatment method for chronic total occlusions if the predilatation result is good.

Coronary perforation with tamponade successfully managed by retrograde and antegrade coil embolization

In recent years, retrograde approach for chronic total occlusions has rapidly evolved, enabling a higher rate of revascularization success. Compared to septal channels, epicardial collaterals tend to be more tortuous, more difficult to negotiate, and more prone to rupture. Coronary perforation is a rare but potentially life-threatening complication of coronary angioplasty, often leading to emergency cardiac surgery. We report a case of a retrograde chronic total occlusion revascularization through epicardial collaterals, complicated by both retrograde and antegrade coronary perforation with tamponade, and successfully managed by coil embolization.

Approach for Chronic Total Occlusion With Intravascular Ultrasound–Guided Reverse Controlled Antegrade and Retrograde Tracking Technique: Single Center Experience

Controlled antegrade and retrograde subintimal tracking (CART) or reverse CART techniques is the final step for percutaneous revascularization of coronary chronic total occlusion (CTO), but it still represents technical challenges and risk in interventional procedures. Our purpose was to utilize intravascular ultrasound (IVUS)-guided reverse CART approach for percutaneous revascularization of CTO in our heart center, focusing on its safety, efficacy, and latest technical developments. From November 2006 to November 2012, 49 patients with CTO failed to antegrade and/or retrograde percutaneous revascularization of CTO from true lumen to true lumen were enrolled in and underwent IVUS guided reverse CART approach. The mean J-CTO score of cases was 2.5. IVUS guidance was successfully implemented in 95.9%; IVUS identified that 61.7% of retrograde wires were located at intimal space, and 59.5% of antegrade wires were located at subintimal space. A Corsair channel dilator was used in 77.6% of cases. The success rates of technique and procedure were 95.9% and 93.9%, respectively; the technical minor complications were observed in 10.2% of cases, without significant clinic outcomes; 2.0% of cases occurred with a major adverse cardiac event of non-ST-elevation myocardial infarction; and no case occurred with target vessel revascularization or death. The mean length of stent implanted in a single CTO vessel was 51.3 mm. No patient appeared with radiation dermatitis and contrast-induced rise of creatinine. IVUS guided reverse CART approach is effective and safe for percutaneous revascularization of complex CTO, with a high success and a low complication rate. It is feasible to develop this approach for percutaneous revascularization of complex CTO. However, suitable case selection and lately device handling by experienced operators are the crucial points of success.

Complications with percutaneous coronary intervention by retrograde approach for chronic total occlusions: data analysis from the Japanese multicenter registry

Complications with percutaneous coronary intervention by retrograde approach for chronic total occlusions: data analysis from the Japanese multicenter registry

Treatment of collateral channel perforation during percutaneous coronary intervention for chronic total occlusion with retrograde approach

We describe one case of septal and two cases of epicardial collateral channel perforation during percutaneous coronary intervention by the retrograde approach for chronic total occlusion. After coil embolization of the channel perforation area, additional treatments were required in all three cases to stop bleeding. All three cases required injection of autologous clots, with one case also requiring subsequent injection of fibrin glue.

Retrograde Approach for Chronic Total Occlusions: The Importance of Experience and Proctorship

Recanalisation of chronic total occlusions has remained suboptimal in the field of percutaneous coronary intervention (PCI). Hopes for a better outcome have been raised since its introduction and evolvement of new techniques, including retrograde approach. Along with conventional antegrade approaches this technique led to a success rate of more than 90% in experienced and chronic total occlusion-dedicated centres. This article focuses on contemporary retrograde approach strategy and the importance of experience and proctorship in PCI of coronary chronic total occlusions (CTO).

Left atrial inflow and outflow obstruction as a complication of retrograde approach for chronic total occlusion

Retrograde recanalization of a chronic coronary total occlusion has become an increasingly utilized method to increase success from percutaneous coronary intervention (PCI). Retrograde wire passage using a septal collateral is the preferred route as the consequences of vessel perforation are more benign than epicardial collateral perforation which may produce cardiac tamponade. Tamponade risk is thought to be lessened by previous coronary bypass surgery due to adhesions preventing free flow of blood throughout the pericardial space. We report the first case of the retrograde approach producing epicardial collateral perforation resulting in a localized epicardial hematoma, which in turn, produced left atrial (LA) inflow and outflow obstruction, with the former producing localized pulmonary edema and pleural effusion. We review reported cases of LA hematoma as a consequence of the antegrade PCI approach and describe a unified explanation for the development of this phenomenon.

レトログレードアプローチを用いたPCIにより川崎病後遺症による成人期の冠動脈慢性完全閉塞病変(CTO)を治療しえた2症例

レトログレードアプローチを用いたPCIにより川崎病後遺症による成人期の冠動脈慢性完全閉塞病変(CTO)を治療しえた2症例

Changing strategies of the retrograde approach for chronic total occlusion during the past 7 years

ObjectiveWe reviewed the technical changes and results achieved with the retrograde approach since we introduced it 7 years ago.Subjects and MethodsThe subjects were 1,268 patients who were treated for CTO between January 2004 and December 2010. They were investigated with respect to the success rate, the frequency of employing the retrograde approach and its outcome, and other factors.ResultsThe retrograde approach was employed in ∼30% of chronic total occlusion (CTO) patients (n = 281) and the retrograde guidewire success rate was 81.1%. The kissing wire technique was substituted for the retrograde approach in 126 of the 281 patients, with antegrade crossing of a guidewire being successful in 88 of them (70%). The retrograde approach was combined with the CART and reverse controlled antegrade retrograde tracking (CART) techniques in 22 and 21 patients, respectively. Among 83 patients treated with Corsair catheters, crossing of the CTO was achieved in 63. The overall procedural success rate was 79.7% (224 patients). Complications of the retrograde approach included collateral channel dissection (2.1%), channel perforation (1.7%), CTO perforation (1.7%), and donor artery occlusion (1.1%).ConclusionThe success rate and safety of the retrograde approach are both satisfactory if the appropriate devices and techniques are selected. © 2012 Wiley Periodicals, Inc.

Percutaneous coronary intervention by retrograde approach for chronic total occlusion of the proximal left anterior descending artery via a gastroepiploic artery graft

Coronary arteries connecting to septal branch are often occluded in post-coronary artery bypass graft cases. A 70-year-old male had undergone CABG; radial artery graft to the LCX, and gastroepiploic artery (GEA) graft to the RCA. Coronary angiography revealed total occlusion in proximal LAD, while both graft vessels had good flow. Retrograde percutaneous coronary intervention (PCI) procedure from the septal channel via GEA graft to the RCA was performed for total occlusion of LAD. Despite the tortuous GEA, deep engagement with a 4-french guiding catheter ensured powerful back-up force. After retrograde wire crossing, two drug-eluting stents were implanted, successfully.