Artery Chronic Total Occlusion Research Articles

Intravascular ultrasound-guided reentry wiring with tip-detection technique for chronic total occlusion of lower extremity artery disease

BackgroundEndovascular therapy is an effective method for revascularization in lower extremity artery disease, but treating chronic total occlusion (CTO) remains challenging. This is particularly true for patients with severe calcification, poor run-off in below-the-knee arteries, or limited access sites, where even guidewire (GW) passage can be difficult and bidirectional approaches are often not feasible. The tip-detection (TD) method has been reported as a useful technique in coronary artery CTO interventions, allowing real-time visualization of the GW tip direction. Here, we applied the TD technique for peripheral CTO intervention.Case presentationCase 1 involved a 71-year-old man with a right toe ulcer. Angiography revealed total occlusion from the right anterior tibial artery (ATA) to the proximal dorsalis pedis artery. While attempting IVUS-guided parallel wiring, the GW could not advance through the intraplaque route because of severe calcification. We intentionally advanced the GW and IVUS into the subintimal space of the ATA to bypass the calcified lesion and performed IVUS-guided reentry using the TD technique in the distal ATA, where calcification was less severe. The second GW successfully passed through the intraplaque of the distal ATA and into the true lumen of the dorsalis pedis artery. Case 2 involved a 60-year-old man with bilateral intermittent claudication. Angiography revealed severe stenosis of the right common iliac artery (CIA) and CTO of the left CIA. Because of anatomical limitations and access site challenges, the antegrade approach for the left CIA was unsuccessful, and retrograde intraluminal wiring was difficult because of flexion and calcification. We advanced the GW and IVUS into the subintimal space and performed IVUS-guided reentry using the TD technique to access the true lumen of the proximal CIA. Finally, bilateral VBX stent grafts were implanted using the kissing stent technique.ConclusionsIVUS-guided reentry wiring with the TD technique may offer a useful solution for passing complex peripheral CTO lesions in cases where only a uni-directional approach is feasible.

Impact of transpedal retrograde wire just marker technique on revascularization of below the knee artery occlusions with ambiguous proximal caps in patients with Buerger's disease.

Chronic total occlusions with ambiguous proximal caps present a significant challenge in endovascular interventions of patients with Buerger's disease. We aimed to evaluate the effectiveness of transpedal retrograde wire just marker technique in patients with Buerger's disease presenting proximal cap ambiguity and flush occlusions. Seventeen patients with the diagnosis of Buerger's disease who had below the knee artery chronic total occlusions with ambiguous proximal caps were enrolled. Procedural success, post-intervention Rutherford stage, wound scores, pedal loop scores, and amputation rates were recorded. Final study group consisted of 13 patients after exclusion of 4 patients due to pedal loop formation failure and severe vasospasm preventing equipment advancement. Post-intervention angiographic success rate was 100%. The post-intervention Rutherford stage showed excellent improvement (mean preprocedural Rutherford stage = 5 vs mean post-intervention Rutherford stage = 2; p = 0.003). Additionally, the average Saint Elian Wound Score System (SEWSS) decreased significantly (Preprocedural 14.9 ± 4.0 vs Postprocedural 11.3 ± 4.7, p < 0.001) after the interventions. Two patients had a major amputation during the follow-up indicating that higher post-intervention pedal loop scores are associated with higher amputation rates. Transpedal retrograde wire just marker technique is an effective and practical method for revascularization of below the knee artery occlusions with ambiguous proximal caps. Including pedal loop angioplasty as a routine part of this technique can significantly increase blood supply to the pedal arch., thereby enhancing the likelihood of wound healing.

Abstract 4138792: A Case of Right Coronary Artery Chronic Total Occlusion in a Transplanted Heart: To Stent or Not to Stent?

Background: Cardiac Allograft Vasculopathy (CAV) is commonly seen in transplanted hearts. Due to the absence of innervation, many transplanted patients have no symptoms despite extensive disease. This poses a challenge in deciding when to perform coronary interventions. We present a case of significant CAV on surveillance angiogram that posed a challenge in management. Case: A 67-year-old female presented for her fifth surveillance coronary angiography nine and a half years after her heart transplant. The angiogram revealed ostial right coronary artery (RCA) chronic total occlusion (CTO) with left-to-right collaterals as well as diffuse irregularities in the left anterior descending (LAD) and left circumflex arteries. The patient was asymptomatic and two years prior to that, her angiogram revealed no significant disease. Biopsies for the past nine years showed no evidence of allograft rejection. She was subsequently referred for coronary intervention. Due to concern of CTO being a sign of rapidly progressing CAV, it was decided to undergo revascularization of the RCA. Antegrade approach was performed with guidance from contralateral injections. Three overlapping drug-eluting stents were deployed proximally-distally using intravascular ultrasound guidance. Surveillance angiography nine months later showed patent RCA stents with no significant disease otherwise. Eighteen months later, angiography demonstrated CTO of the mid LAD and patent RCA stents with mild in-stent restenosis in the most distal RCA stent. The patient remained asymptomatic. Discussion: CAV develops in fifty percent of transplanted hearts within 10 years and requires close surveillance. In this case, revascularization of the RCA CTO resulted in maintaining graft function for at least two additional years as the development of LAD CTO may have resulted in graft failure had the RCA CTO not been intervened upon. CTO revascularization in CAV has the potential to prolong graft viability and delay the need for re-transplantation. Further studies related to CTO revascularization, especially in asymptomatic transplanted patients, are needed to understand the impact on morbidity and mortality in this patient population.

Abstract 4137144: Return to Cath Lab: Chest Pain Resolution after Right Coronary Artery Chronic Total Occlusion Intervention

Introduction: Subacute stent thrombosis (ST) is related to high rates of cardiac reinfarction. We present a case of reinfarction from ST. The patient’s chest pain (CP) was not alleviated with initial revascularization of his left circumflex (LCx) ST, requiring PCI to his right coronary artery (RCA) chronic total occlusion (CTO). This is a novel approach to CTO PCI which is traditionally a non-urgent procedure. Case: A 53-year-old male with a history of coronary artery disease and surgical turndown presented to the ED with CP. Two weeks prior he had impella guided LM bifurcation PCI with DES and ramus intermedius (RI) angioplasty (PTA) but was nonadherent to clopidogrel. He had a BP of 127/85, HR of 65, and was on room air. Exam was unremarkable. His EKG was in sinus rhythm with S-T depressions ~1mm in leads V1-V4 concerning for posterior infarction. HS-troponin (HST) was 60. Angiography (CA) showed thrombotic occlusion of his LCx DES (Fig 1a) and an RCA CTO (Fig 1c). Optical coherence tomography (OCT) revealed DES struts overlying the ostial LCx concerning for mechanical deformation from carinal shift. OCT guided PTA and laser thrombectomy (LT) of the LCx led to TIMI-3 Flow. LT and kissing balloon inflation (BI) was performed on the LAD and LCx to reshape the carina. HST peaked at 116,012. He had CCS Class IV CP despite medical therapy and returned for re-look CA with TIMI-3 flow in the left-sided circulation without thrombus (Fig 1b). He had PCI to his distal RCA CTO with two DES and TIMI-3 flow in the RCA (Fig 1d). He did not have recurrence of CP. Discussion: Bifurcation PCI leads to challenges from anatomic reconfiguration, metallic DES deformity, and changes in blood flow leading to increased risk of distal ST. This patient’s CA demonstrated LM DES material overlying the LCx from carinal shifting which likely led to interrupted flow dynamics. His LCx ST was partly due to this stasis and his clopidogrel nonadherence. Despite PCI of his LCx his CP remained with poor collateral flow from the left circulation. While CTO procedures are typically done non urgently, emergent intervention on our patient’s RCA CTO led to complete resolution of his CP and clear benefit for symptomatic management.

TCT-693 Clinical Outcome of Between Low- and High-Dose Drug-Coated Balloon Angioplasty Performing Intraplaque Wiring for Femoropopliteal Artery Chronic Total Occlusion Lesions

TCT-693 Clinical Outcome of Between Low- and High-Dose Drug-Coated Balloon Angioplasty Performing Intraplaque Wiring for Femoropopliteal Artery Chronic Total Occlusion Lesions

TCT-400 In-Hospital Outcome of Antegrade Dissection Reentry in Left Anterior Descending Artery Chronic Total Occlusions: Patient Data Pooled Analysis of 4 Multicenter Registries

TCT-400 In-Hospital Outcome of Antegrade Dissection Reentry in Left Anterior Descending Artery Chronic Total Occlusions: Patient Data Pooled Analysis of 4 Multicenter Registries

The Untold Story: Early and Mid-Term Results of Subintimal Angioplasty in Superficial Femoral Artery Versus Popliteal Artery Chronic Total Occlusion.

This study aims to compare the immediate and mid-term outcomes of subintimal angioplasty (SIA) of chronic total occlusions (CTOs) of superficial femoral artery (SFA) versus popliteal artery (PA) and to identify possible predictors of loss of limb-based patency (LBP). This is a retrospective analysis of chronic lower-limb ischemia (CLI) patients (Rutherford classes 3-6) presenting with CTO of SFA or PA treated by SIA and selective stenting in the period 2018 to 2021. Immediate outcomes were compared between the SFA and PA groups, including technical success, perioperative complications, and 30-day major amputation and mortality rates. Mid-term outcomes for technically successful procedures included limb-based patency (LBP), wound healing rate, amputation-free survival (AFS), and major adverse limb events (MALEs). A total of 450 CLI patients underwent SIA of CTO at the SFA (n=260, 57.8%) and the PA (n=190, 42.2%). The indication for revascularization was chronic limb-threatening ischemia in 80.8% of SFA group and 84.2% of PA group. Technical success rate was higher in the PA group compared to the SFA group (96.3% vs 91.2%; p=0.03). The 30-day amputation rates were comparable between the SFA and PA groups (7.7% vs 6.8%, p=0.7, respectively). No perioperative mortality or systemic major complications occurred in the present study. Kaplan-Meier estimate of the 1-year rates were significantly better for SFA group regarding LBP (82% for SFA group vs 43% for PA group, p=0.006), AFS (88% vs 64%, p=0.02), and wound healing (79% vs 58%, p=0.027), respectively. The number of runoff vessels was the only factor associated with loss of LBP (hazard ratio [HR], 0.055; 95% confidence interval [CI]: 0.001-3.020, p=0.039). Subintimal angioplasty is an effective and safe endovascular treatment option of CTO at SFA and PA with satisfactory immediate outcomes. The mid-term outcomes, however, are better for SFA lesions in terms of improved LBP, AFS, and wound healing rates. Subintimal angioplasty is a valuable tool in the armamentarium of endovascular surgeons, as re-entry devices aren't always widely accessible. This study aims to assess the technical outcomes of peripheral vascular interventions for infrainguinal chronic total occlusions and identify possible predictors for successful subintimal angioplasty .Subintimal angioplasty is an effective treatment option for infrainguinal CTO with difference in result of immediate outcomes in popliteal lesions and SFA lesions.

Chronic total occlusions and coronary artery bypass grafting outcomes

ObjectiveTo investigate the association between the presence and grafting of chronic total occlusions (CTOs) and coronary artery bypass grafting (CABG) outcomes. MethodsThis was a post hoc analysis of the Randomized Endograft vs Open Prospective (REGROUP) trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest (2014-2017). Patients were stratified on the basis of the presence of at least 1 CTO vessel (a 100% occluded coronary lesion for greater than or equal to 3 months) and according to whether all CTO vessels were bypassed. Rates of major cardiac adverse events (MACE) were compared. ResultsAt least 1 CTO was present in 453 of 1149 patients (39.4%). Over a median follow-up of 4.7 years (interquartile range, 3.84-5.45), MACE rates were 23.4% versus 22.2% for the CTO versus no CTO group, respectively (adjusted hazard ratio [aHR], 0.92; 95% confidence interval [CI], 0.70-1.20). MACE rates for patients with complete CTO grafting versus not were 23.1% versus 25.0%, respectively (aHR, 0.95; 95% CI, 0.57-1.57). In patients with right coronary dominance undergoing left anterior descending artery grafting, bypassing a right coronary artery CTO was associated with significantly lower rates of all-cause mortality (aHR, 0.38; 95% CI, 0.17-0.83). ConclusionsIn this REGROUP trial subanalysis, neither CTO presence or complete grafting of CTO vessels was associated with significantly different rates of MACE. However, the finding of possible survival benefit among a subgroup of patients undergoing grafting of a dominant RCA CTO vessel alongside left anterior descending artery grafting warrants additional study.

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion

PurposeThis retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting. MethodsThis treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1–P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter. ResultsForty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period. ConclusionThe endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

Retrograde Peroneal Artery Approach to Treat Infra-Inguinal Arterial Chronic Total Occlusions: A Multicentre Experience and Technical Considerations.

Background/Objectives: Retrograde access of the peroneal artery (PA) is considered technically challenging and at risk of bleeding. The aim of this multicentre retrospective study was to assess the safety, feasibility, and technical success of this access route for infrainguinal endovascular recanalizations. Methods: We retrospectively analyzed 186 consecutive patients treated over a 7-year period (May 2014-August 2021) who underwent endovascular recanalization of infra-inguinal lesions using a PA access route. In all cases, retrograde PA access was obtained following a failed attempt to cross the occlusion via the antegrade route. Results: Among the 186 patients, 120 were males (60.5%) and the mean age was 76.8 ± 10.7 years old (44-94 years). One hundred and thirteen patients (60.7%) suffered from chronic limb threatening ischemia (CLTI). All patients presented with chronic total occlusions (CTO) and a failed conventional antegrade recanalization attempt. Retrograde access was performed under angiographic guidance in 185 cases (99.5%). It was successfully established in 171 cases (91.9%). The total rate of retrograde puncture-related complications was 2.1% (two puncture site bleedings of which one necessitated fasciotomy and two cases of arteriovenous fistulas managed conservatively). The Major Adverse Event (MAE) rate at 30 days was 1.6% (3/186). Conclusions: Retrograde recanalization of challenging infra-inguinal lesions via PA is safe and effective in experienced hands.

OR4-2 | Percutaneous Coronary Intervention Versus Robotic-Assisted Coronary Artery Bypass for Left Anterior Descending Artery Chronic Total Occlusion

OR4-2 | Percutaneous Coronary Intervention Versus Robotic-Assisted Coronary Artery Bypass for Left Anterior Descending Artery Chronic Total Occlusion

High Sensitivity Troponin Level and Benefits of Chronic Total Occlusion Revascularization.

Background The survival benefit of revascularization of chronic total occlusion (CTO) of the coronary arteries remains a subject of controversy. We measured high sensitivity troponin-I (hsTn-I) levels as an estimate of myocardial ischemia in patients with stable coronary artery disease, with the hypothesis that (1) patients with CTO have higher levels of hsTn-I than patients without CTO, (2) hsTn-I levels will predict adverse cardiovascular events in patients with CTO, and (3) patients with elevated hsTn-I levels will have a survival benefit from CTO revascularization. Methods and Results In 428 patients with stable coronary artery disease and CTO undergoing coronary angiography, adverse event rates were investigated. Cox proportional hazards models and Fine and Gray subdistribution hazard models were performed to determine the association between hsTn-I level and incident event rates in patients with CTO. HsTn-I levels were higher in patients with compared with those without CTO (median 6.7 versus 5.6 ng/L, P=0.002). An elevated hsTn-I level was associated with higher adverse event rates (adjusted all-cause mortality hazard ratio, 1.19 [95% CI, 1.08-1.32]; P=0.030) for every doubling of hsTn-I level. CTO revascularization was performed in 28.3% of patients. In patients with a high (>median) hsTn-I level, CTO revascularization was associated with substantially lower all-cause mortality (adjusted hazard ratio, 0.26 [95% CI, 0.08-0.88]; P=0.030) compared with those who did not undergo revascularization. In patients with a low (<median) hsTn-I level, event rates were similar in those with and without CTO revascularization. Conclusions HsTn-I levels may help identify individuals who benefit from CTO revascularization.

Abstract 164: Chronic Total Occlusion of the Bilateral Internal Carotid Arteries, Vertebral Arteries and Basilar Artery

Introduction Bilateral internal carotid arteries (ICAs), vertebral arteries (VAs), and basilar artery chronic total occlusion is an exceedingly rare condition. Possible underlying etiologies include atherosclerosis, Moyamoya disease, dissection, among others. Methods Here we describe a 58‐year‐old man with chronic total occlusion of the bilateral ICAs, VAs and basilar artery of unknown etiology. Results A 58‐year‐old man who is independent for ADLs/iADLs with a history of prior ischemic strokes (first stroke at 40 years old) with residual left‐sided weakness and dysarthria, hypertension, hyperlipidemia, prior blood clots (previously on warfarin), post‐stroke epilepsy, and never smoker presented as a code stroke to the emergency department after waking that morning with worsening of his residual left‐sided weakness and dysarthria. On arrival, blood pressure was 165/94 mmHg and blood glucose was 108 mg/dL. His NIHSS was 6. His neurologic exam was grossly similar to that documented 19 months ago. In the CT scanner, he developed tonic‐clonic movements of the left arm and leg, confusion, and emesis. Later, he stated he had missed several doses of his prescribed levetiracetam. Head CT and brain MRI revealed encephalomalacia in the brainstem and bilateral cerebellar and cerebral hemispheres. Brain MRI did not demonstrate any diffusion restriction changes. CTA showed chronic occlusion of both ICAs (proximal, distal, and terminus), M1s, VAs (V4 segment), and basilar artery. CTA also revealed that the brain parenchyma was being perfused by collaterals between the external carotid artery (ECA) branches, superficial temporal artery, and M2 branches bilaterally and the bilateral posterior circulation arteries were small and reformed through collaterals. CTP showed a core and penumbra volumes of 0 mL. His presentation was consistent with a seizure. He was admitted to the stroke service for work‐up of his abnormal brain vasculature. Catheter angiography confirmed the CTA results demonstrating occluded bilateral cervical and intracranial segments of the ICAs, collaterals from bilateral ECA branches supplying the intracranial circulation, right VA occlusion distal to the right PICA, and left VA occlusion distal to the V3 segment. Remaining work‐up including A1c, LDL, urine drug screen, EKG, transthoracic echocardiogram, and telemetry was unrevealing other than for an LDL of 152. Routine EEG showed moderate generalized showing. During hospitalization, his home amlodipine and losartan medications were discontinued with the goal of maintaining a blood pressure target of 140‐160 systolic indefinitely, to minimize the risk of hypoperfusion cerebrally. Give his robust collaterals, surgical treatment with revascularization was not pursued. His home aspirin and rosuvastatin 40 mg daily were continued and ezetimibe 10 mg daily was added. His home levetiracetam was increased from 500 to 750 mg twice daily given recent unprovoked seizures at home. He was discharged to an inpatient rehabilitation facility. Conclusion To our knowledge, this is the first case report to show chronic total occlusion of the bilateral ICAs, VAs, and basilar artery. Diagnosis of Moyamoya disease stage VI ("disappearance of the Moyamoya") was entertained but felt to be less likely given involvement of the proximal ICAs and posterior circulation. Other diagnostic consideration included atherosclerosis. Overall, the underlying etiology of his condition remained elusive.

“Catheter Kissing” Technique to Recanalize Chronic Total Occlusions in Iliac Artery with Wire-Catheter Approach

PurposeTo describe a technique in which two 5-F curved catheters were utilized to facilitate the wire-catheter approach for recanalizing chronic total occlusions (CTOs) in the iliac arteries concurrently affecting the common iliac artery and external iliac artery. MethodsThis was a single-center retrospective analysis involving endovascular recanalization of 17 iliac artery CTOs in 15 patients (mean age: 73.66 years; all men) between January 2019 and October 2022 using the subintimal arterial flossing with antegrade–retrograde intervention technique. With antegrade and retrograde guidewires in the subintimal spaces of CTOs, the location where the two guidewires seemed to overlap was identified as the rendezvous point. Although the two guidewires appeared to be in close proximity, there was no evidence that the bidirectional subintimal channels were connected. If several initial attempts failed, two 5-F multipurpose catheters were introduced to the rendezvous point, followed by twisting, pulling, and pushing maneuvers until the tips of the catheters touched, indicating that the bidirectional subintimal channels were joined. A second wire rendezvous attempt was then employed to create a flossing-type guidewire. Outcome measurements included technical success, rendezvous points, complications, and procedure duration. ResultsAmong this cohort, 80.0% smoked and 66.7% had hypertension. In 11 limbs (64.7%), when initial wire rendezvous attempts failed, the "catheter kissing" technique was employed to successfully recanalize iliac artery CTOs, taking an average of 3.80 ± 1.64 minutes to complete the secondary wire rendezvous. The average length of CTOs was 111.06 ± 9.99 mm, with 7 (41.2%) and 8 (47.1%) cases exhibiting severe calcification and flush occlusion, respectively. The wire rendezvous point for all cases was in EIA and the average time for successful secondary wire rendezvous was 3.80 ± 1.64 minutes. All patients were treated with iliac artery stents. No statistically significant difference was observed between the puncture sites of the common femoral artery and superficial femoral artery in relation to failure of the primary wire rendezvous (p = 0.644). No in-hospital deaths or complications were associated with the procedure, including iliac artery rupture, distal embolization, or access site complications. ConclusionIn patients with extensive iliac artery CTOs, the "catheter kissing" technique may offer an effective and time-efficient recanalization approach, without requiring additional specialized devices. Importantly, the risk of complications remains unchanged even when employing a wire rendezvous in a challenging subintimal space.

Performance of BeBack Crossing Catheter in Chronic Total Occlusion in Patients With Chronic Limb-Threatening Ischemia: A Single-Center Experience.

To describe a single-center experience in the treatment of chronic limb-threatening ischemia (CLTI) with the application of BeBack catheter (Bentley InnoMed, Germany) in patients with arterial chronic total occlusion (CTO). A retrospective review of patients who underwent limb revascularizations using the BeBack catheter between 2015 and 2022. All patients had an initial failed attempt using a traditional guidewire and catheter technique. Technical success was considered whenever a successful re-entry or lesion crossing using the study device was achieved. Procedural success was defined as recanalization of the occluded artery with residual stenosis of less than 30%, and improvement in ankle-brachial index (ABI) after 24 hours. A Rutherford score was assigned to each limb and affected anatomical segments and lesion length were documented. Procedural access sites and complications were noted. The study included 72 patients who underwent 78 procedures using the BeBack crossing catheter. Procedural success was achieved in 91% of cases, with a technical success rate of 92.3%. The most frequently involved occluded segments were the femoral and popliteal arteries. The average ABI improved from 0.59 to 0.95 after the procedure. The most used access site was the contralateral femoral, and the BeBack catheter was employed on 85 occasions. Only 1 patient suffered a severe immediate adverse effect, and during the 30-day follow-up period, 2 patients needed reintervention. Unfortunately, 3 patients died during the follow-up period. The BeBack catheter offers a viable option for the treatment of patients with chronic total occlusion, with high procedural success and a low complication rate. The BeBack catheter presents a notable advancement for clinicians managing chronic limb-threatening ischemia (CLTI) and arterial chronic total occlusion (CTO), showcasing over 90% procedural and technical success rates in this study. Its adept ability to navigate and recanalize occluded segments provides a robust alternative, especially when traditional techniques falter. This innovation may chane clinical strategies in vascular interventions, offering an efficient and reliable option, thereby potentially enhancing patient outcomes in limb revascularizations.

Accurate Prediction of Retrograde Collateral Channel Crossing in Coronary Artery Chronic Total Occlusion Intervention

Successful collateral channel (CC) crossing is an essential step in retrograde chronic total occlusion (CTO) percutaneous coronary interventions (PCI). We previously developed a dedicated CC score based on CC size and tortuosity to facilitate target CC selection. Validation and comparison to other scoring systems were lacking. Thus, the aims of this study were to 1) validate the CC score in a larger independent cohort, and 2) compare its accuracy and clinical usefulness with the J-channel score. All coronary CTO PCIs attempted by experienced high-volume operators from January, 2017 to December, 2021 were enrolled. The CC and J-channel scores were calculated for all attempted CCs with bi-plane high-resolution cine angiography images. CC crossing success was defined as guidewire reaching the distal true lumen retrogradely. In total, 502 patients who received CTO PCI were included. The retrograde approach was utilized in 244 target CTOs, and a total of 329 CCs were attempted. The overall CC crossing rate was 67.8% (223/329) and final technical success rate 92.2% (225/244). The average CC score was 2.0 and average J-channel score was 0.71. The sensitivity and specificity of successful CC crossing with the CC score ≥2 were 81.2%, and 84.0%, respectively. Comparison between the CC score (area under the curve [AUC] 0.87; 95% confidence interval [CI] 0.83-0.90) and the J-channel score (AUC 0.61; 95% CI 0.55-0.67) demonstrated superior predictive performance of the CC score (p <0.001). The CC score was an easy-to-use and accurate tool for the prediction of successful CC crossing in retrograde CTO PCI. The CC score can help operators select the ideal target CC, thereby facilitating final procedural success.

TCT-607 Machine Learning for Predicting Major Adverse Cardiac Events in Percutaneous Coronary Intervention of Coronary Artery Chronic Total Occlusion

TCT-607 Machine Learning for Predicting Major Adverse Cardiac Events in Percutaneous Coronary Intervention of Coronary Artery Chronic Total Occlusion

Modified bare-back micro-retrograde tibial arterial access to facilitate peripheral endovascular therapy.

Patients with critical limb threatening ischemia often present with complex segmental peripheral arterial chronic total occlusions, which might not be amenable to traditional antegrade revascularization techniques. For these patients, alternative retrograde revascularization techniques could be necessary. In the present report, we describe a novel modified retrograde cannulation technique using a bare back technique that eliminates the need for conventional tibial access sheath placement and, instead, facilitates distal arterial blood sampling, blood pressure monitoring, retrograde administration of contrast agents and vasoactive substances, and a rapid-exchange strategy. This cannulation strategy can serve as part of the armamentarium in the treatment of patients with complex peripheral arterial occlusions.

Clinical and Procedural Outcomes of IVUS-Guided vs. Angiography-Guided CTO-PCI: A Systematic Review and Meta-Analysis.

Chronic total occlusions (CTO) in coronary angiographies present a significant challenge nowadays. Intravascular ultrasound (IVUS) is a valuable tool during CTO-PCI, aiding in planning and achieving procedural success. However, the impact of IVUS on clinical and procedural outcomes in CTO-PCI remains uncertain. This meta-analysis aimed to compare IVUS-guided and angiography-guided approaches in CTO-PCI. The study included five studies and 2320 patients with stable coronary artery disease (CAD) and CTO. The primary outcome of major adverse cardiac events (MACE) did not significantly differ between the groups (p = 0.40). Stent thrombosis was the only secondary clinical outcome that showed a significant difference, favoring the IVUS-guided approach (p = 0.01). Procedural outcomes revealed that IVUS-guided procedures had longer stents, larger diameters, and longer procedure and fluoroscopy times (p = 0.007, p < 0.001, p = 0.03, p = 0.002, respectively). Stent number and contrast volume did not significantly differ between the approaches (p = 0.88 and p = 0.33, respectively). In summary, routine IVUS use did not significantly improve clinical outcomes, except for reducing stent thrombosis. Decisions in CTO-PCI should be individualized based on patient characteristics and supported by a multi-parametric approach.

Percutaneous Coronary Intervention for Chronic Total Occlusion-Contemporary Approach and Future Directions.

In the aging society, the issue of coronary chronic total occlusion (CTO) has become a challenge for invasive cardiologists. Despite the lack of clear indications in European and American guidelines, the rates of percutaneous coronary interventions (PCI) for CTO increased over the last years. Well-conducted randomized clinical trials (RCT) and large observational studies brought significant and substantial progress in many CTO blind spots. However, the results regarding the rationale behind revascularization and the long-term benefit of CTO are inconclusive. Knowing the uncertainties regarding PCI CTO, our work sought to sum up and provide a comprehensive review of the latest evidence on percutaneous recanalization of coronary artery chronic total occlusion.