Chronic Total Occlusion Lesions Research Articles

Identification of micro-channels within chronic total occlusions using contrast-enhanced ultrasound

BackgroundVascular micro-channels within chronic total occlusions (CTO) have been identified in histopathology and animal studies. They have been proposed as a potential path for achieving endovascular crossing via the lumen. There are currently no noninvasive means of imaging these structures. The aim of this study was to investigate whether contrast-enhanced ultrasound (CEUS) examination can identify micro-channels within CTO in humans. MethodsCTO within the femoropopliteal arteries were imaged with CEUS examination in 38 patients. Segments containing micro-channels were identified and their length measured. The proportion of occlusion length containing micro-channels was assessed for each case. Micro-channel appearances including linear or tortuous configuration, crossing of occlusion caps, and connections to vasa vasorum were recorded. ResultsThe median CTO length was 17.0 cm (interquartile range [IQR], 6.9-27.9 cm) and median age of CTO was 12 months (IQR, 6-16 months). Micro-channels were identified in 92.1% of cases (35/38). The median length within a lesion containing micro-channels was 6.4 cm (IQR, 2.4-14.3 cm) and median proportion of CTO containing micro-channels was 47.9% (IQR, 1.7%-28.5%). A linear micro-channel configuration was seen in 84.2% of cases and a tortuous configuration was seen in 57.9% of cases. Micro-channel connections through the cap were seen in 50% (19/38 cases) and connections to the vasa vasorum in 71.1% (27/38 cases). No association was found between the proportion of each lesion containing micro-channels and CTO age, lesion length or calcification severity. There were no adverse effects related to contrast use. ConclusionsCEUS can be used to detect micro-channels in CTO in human femoropopliteal arteries. This imaging technique is safe and minimally invasive and may represent a practical method for selection of occlusion crossing method. Further work is required to determine whether identification of micro-channels can be used to improve treatment decision-making and provide a better understanding of the natural history of femoropopliteal CTO.

Endovascular treatment of chronic total occlusion of superficial femoral artery using retrograde approach from popliteal artery

An 55 years-old man with intermittent claudication was admitted to Hue central Hospital. Doppler ultrasound and digital subtraction angiography showed his left superficial femoral artery (SFA) was chronic total occlusion (CTO), and we performed endovascular treatment (EVT). We advanced a guide-wire by contralateral transfemoral approach, but guide-wire could not penetrate the occluded SFA lesion antegradely. Thus, we tried to approach the CTO lesion retrogradely. A guide-wire passed from popliteal artery to distal SFA. With a reverse-controlled antegrade and retrograde approach technique, we were able to pass the CTO lesion. Finally, two stents were implanted. We experienced a case in which retrograde approach via collateral channel from popliteal artery was effective to CTO of SFA.

Impact of Chronic Kidney Disease on Chronic Total Occlusion Revascularization Outcomes: A Meta-Analysis.

Objectives: To examine the impact of revascularization and associated clinical outcomes of chronic kidney disease (CKD) chronic total occlusion (CTO) and non-CKD CTO groups. Background: The influence of CKD on clinical outcomes after percutaneous coronary intervention (PCI) for CTO lesions is unknown, and there is no systemic review of this topic to date. Methods: We searched the PubMed, Embase, ProQuest, ScienceDirect, Cochrane Library, ClinicalKey, Web of Science, and ClinicalTrials Databases for articles published between 1 January 2010 and 31 March 2020. CKD was defined as estimated glomerular filtration rate of <60 mL/min/1.73 m2 according to the Modification of Diet in Renal Disease formula. Data included demographics, lesion distributions, incidence of contrast-induced nephropathy (CIN), acute kidney injury (AKI), procedural success rate, mortality, and target lesion revascularization (TLR)/target vessel revascularization (TVR). Results: Six studies were ultimately included in this systematic review. A high prevalence (25.5%; range, 19.6–37.9%) of CKD was noted in the CTO population. In the non-CKD group, outcomes were better: less incidence of CIN or AKI (odds ratio (OR), 2.860; 95% confidence interval (CI), 1.775–4.608), higher procedural success rate (OR, 1.382; 95% CI, 1.036–1.843), and lower long-term mortality (OR, 4.502; 95% CI, 3.561–5.693). The incidence of TLR/TVR (OR, 1.118; 95% CI, 0.888–1.407) did not differ between groups. Conclusions: In the CKD CTO PCI population, a lower procedural success rate, a higher incidence of CIN or AKI, and higher in-hospital and long-term mortality rate were noted due to more complex lesions and more comorbidities. However, the incidence of TLR/TVR did not differ between groups.

Association between angiographic and intravascular ultrasound optimizations after new-generation drug-eluting stent implantation and clinical outcomes.

Uncertainty remains regarding the associations of angiographic optimization and intravascular ultrasound (IVUS) optimization after new-generation drug-eluting stent (DES) implantation. From four randomized trials comparing outcomes between IVUS and angiography-guidance for long or chronic total occlusion (CTO) lesions, 1396 patients who underwent IVUS-guided new-generation DES implantation were enrolled. Of these, 1112 patients (80%) met angiographic optimization criteria (postprocedural diameter stenosis, ≤20%) and were further classified into the matched (same results for angiographic optimization and IVUS optimization) and the mismatched group (opposite results for angiographic optimization and IVUS optimization) according to the meeting of IVUS optimization criteria (minimal stent area, ≥5.5 mm2 or ≥80% of mean reference lumen area). The major adverse clinical events (MACE) were compared. Of 1112 patients with angiographic optimization, 675 patients met the IVUS optimization criteria (61%; matched), but 437 patients (39%; mismatched) failed to meet IVUS optimization criteria (false-positive rate = 76%). On multivariate analyses, age >60 years, reference vessel diameter ≤2.7 mm, left circumflex artery and lesion length ≥33 mm were significant predictors for the mismatched. When comparing the 12-month MACE rates, the mismatched group (6.8%) showed a significantly higher rate than the matched group (1.5%; hazard ratio = 2.62; 95% confidence interval = 1.20-5.72; P = 0.012), mainly driven by a higher target-vessel revascularization rate (6.4 vs 1.4%; P = 0.021). Despite meeting angiographic optimization criteria in long or CTO lesions, more than one-third of the patients with IVUS-guided new-generation DES implantation failed to meet the IVUS optimization criteria and had worse clinical outcomes. Therefore, IVUS optimization should be considered for patients who had predictors of mismatch.

Practical utilization of cardiac computed tomography for the success in complex coronary intervention.

Percutaneous coronary intervention (PCI) for complex lesions is still technically demanding and is associated with less favorable procedural parameters such as lower success rate, longer procedural time, higher contrast volume and unexpected complications. Because the conventional angiographic analysis is limited by the inability to visualize the plaque information and the occluded segment, cardiac computed tomography has evolved as an adjunct to invasive angiography to better characterize coronary lesions to improve success rates of PCI. Adding to routine image reconstructions by coronary computed tomography angiography, the thin-slab maximum intensity projection method, which is a handy reconstruction technique on an ordinary workstation, could provide easy-to-understand images to reveal the anatomical characteristics and the lumen and plaque information simultaneously, and then assist to build an in-depth strategy for PCI. Especially in the treatment of chronic total occlusion lesion, these informations have big advantages in the visualization of the morphologies of entry and exit, the occluded segment and the distribution of calcium compared to invasive coronary angiography. Despite of the additional radiation exposure, contrast use and cost for cardiac computed tomography, the precise analysis of lesion characteristics would consequently improve the procedural success and prevent the complication in complex PCI.

Endovascular revascularization of chronic total arterial occlusion of the lower limb using the SAFARI technique.

The SAFARI technique or Subintimal Arterial Flossing with Antegrade-Retrograde Intervention is an endovascular procedure that allows recanalization of Chronic Total Occlusive (CTO) lesions when conventional subintimal angioplasty is unsuccessful. Retrograde access is usually obtained through the popliteal, anterior tibial, dorsalis pedis artery, or posterior tibial arteries and may potentially provide more options for endovascular interventions in limb salvage. The case of an 81-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and dyslipidemia is presented. He presented with a cutaneous ulcer on the right lower limb with torpid evolution and poor healing. The Doppler ultrasound and arteriographic study revealed a CTO lesion of the popliteal artery that was not a candidate for antegrade endovascular revascularization, but was successfully treated using the SAFARI technique. The patient had no perioperative complications, the wound showed better healing, and he was discharged with an indication of daily dressings and control by an external outpatient clinic.

Complex Coronary Instent Chronic Total Occlusion Lesions: Oxidative Stress, Inflammation, and Coronary Stent Lengths.

The oxidative stress and inflammation played the key roles in the development of atherosclerotic coronary plaques. However, the relationships between pro/antioxidant, pro/anti-inflammatory status, and complex coronary instent chronic total occlusion lesions were not clear in the elderly patients with very long stent implantations. We tried to evaluate the roles of pro/antioxidant and pro/anti-inflammatory biomarkers in the diagnosis of complex reocclusion lesions in elderly patients after coronary stenting. We evaluated the expression levels of acrolein (ACR), malondialdehyde (MDA), high sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), superoxide dismutase 3 (SOD3), paraoxonase-1 (PON-1), endothelial nitric oxide synthase (eNOS), and stromal cell-derived factor-1α (SDF-1α) in the elderly patients with very long stent implantations and complex reocclusion lesions. Levels of ACR, MDA, hs-CRP, and TNF-α were remarkably increased (P < 0.001), and levels of SOD3, PON-1, eNOS, and SDF-1α were decreased significantly (P < 0.001) in the elderly patients with very long stents and complex reocclusion lesions. The prooxidant and proinflammatory biomarkers were remarkably increased, as well as antioxidant and anti-inflammatory biomarkers were decreased significantly in the elderly patients with very long stent implantations and complex reocclusion lesions after coronary stenting. In conclusion, these findings indicated that the imbalance between prooxidant/proinflammatory and antioxidant/anti-inflammatory status was associated with complex reocclusion lesions, suggesting that oxidative stress and inflammation played the key roles in progression of complex reocclusion lesions in the elderly patients with very long stent implantations.

Cardiac and sudden death after chronic total occlusion percutaneous coronary intervention: Prognostic role of the target vessel.

The role of the target vessel in percutaneous revascularization of chronic total occlusion (CTO) is unclear. We sought to assess the long-term results of percutaneous coronary intervention (PCI) for CTO lesions in each coronary artery and to investigate the impact of successful revascularization and previous myocardial infarction (MI) in the territory of the target vessel. Cohort observational study on 1,124 patients who have undergone CTO PCI attempt: 371 on left anterior descending artery (LAD), 485 right coronary artery, and 268 left circumflex. Patients were further stratified by successfully revascularized and not-revascularized CTO (CTO-NR). Vessels affected by a previous MI were defined as infarct-related artery (IRA). The primary endpoint was cardiac death; the secondary endpoint was the combined rate of sudden cardiac-death and sustained ventricular-arrhythmias (SCD/SVAs). Propensity score-matching was performed to evaluate LAD versus NON-LAD CTO. Up to 12-year follow-up, the clinical benefit associated with successful PCI was consistent across the three groups. CTO-NR had the greatest association with cardiac death and SCD/SVAs in each coronary artery and in IRA-CTO patients. Unsuccessful percutaneous CTO revascularization was associated with lower cardiac survival and freedom from SCD/SVAs, irrespective of the vessel treated. This result was mainly driven by patients with an IRA CTO.

Angiographical coronary artery calcification predicts antegrade guidewire crossing during percutaneous coronary intervention of chronic total occlusion

Background: Coronary artery calcification (CAC) is a predictor of failed revascularization in Chronic Total Occlusion (CTO) Percutaneous Coronary Intervention (PCI). However, CTO PCI operators believe that angiographical CAC shows promise as a landmark in the manipulation of antegrade guidewire crossing. We aimed to identify the relationship between angiographical CAC and successful antegrade guidewire crossing in CTO PCI. Methods and Findings: This single-center, retrospective, observational study enrolled 48 consecutive patients who underwent Coronary Computed Tomography Angiography (CCTA) before PCI for CTO. They were divided, according to the level of antegrade guidewire crossing success, into the success (≤ 30 min; n=25, 50%) and unsuccess (>30 min; n=25, 50%) groups. All the CCTA and coronary angiographic findings obtained before PCI were analyzed. We assessed the relationship between angiographical CAC and successful antegrade guidewire crossing and other factors associated with it. The baseline characteristics were similar between the groups. Angiographical CAC was more frequently observed in the success group than in the unsuccess group (68% vs. 24%, p=0.080). There were no statistically significant differences in the CTO entry morphology, bridging collateral, vessel bending, distal reference diameter, occlusion length, and calcification severity between the groups. In the multivariable analysis, angiographical CAC in the CTO lesion predicted successful antegrade guidewire crossing within 30 min (odds ratio=0.043, 95% confidence interval=0.003–0.614, p=0.006). Conclusion: Angiographical CAC may be a promising landmark for antegrade wire manipulation in patients with CTO. Abbreviations: CAC: Coronary Artery Calcification; CAG: Coronary Angiography; CART: Controlled Antegrade and Retrograde Subintimal Tracking; CCTA: Coronary Computed Tomography Angiography; CTO: Chronic Total Occlusion; IVUS: Intravascular Ultrasound; J-CTO: Multicenter CTO Registry of Japan; LAD: Left Descending Artery; LCX: Left Circumflex Artery; PCI: Percutaneous Coronary Intervention; RCA: Right Coronary Artery; TIMI: Thrombolysis in Myocardial Infarction

Management of Chronic Total Occlusion of Coronary Artery.

Chronic total occlusion (CTO) of a coronary artery is typically defined as a completely occluded artery without any antegrade flow and a duration of at least 3 months. We reviewed the current literature describing the optimal management of CTO including the role of revascularization and choice of modality, i.e., percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery. Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL) were searched and relevant studies of patients with CTO were selected for review. The prevalence of coronary artery CTOs is approximately 25% among patients undergoing coronary angiography for angina. Available data suggests that PCI of CTO can be a technically complex procedure with relatively lower success rates compared with non-CTO PCI and typically associated with a higher complication rate especially at nonspecialized centers. Furthermore, successful CTO-PCI is associated with symptomatic improvement but does not appear to improve mortality, myocardial infarction, stroke, and repeat revascularization rates. Based on contemporary data, PCI of CTO lesions may be considered in patients with incapacitating angina despite treatment with optimal guideline-directed medical therapy and in whom based on coronary anatomy there is a reasonable chance of technical success with an acceptable risk.

Clinical outcomes of complete versus incomplete revascularization in patients treated with coronary artery bypass grafting: insights from the TiCAB trial.

In this post hoc analysis of the Ticagrelor in coronary artery bypass grafting (CABG) trial, we aimed to analyse patients treated with CABG receiving either complete revascularization (CR) or incomplete revascularization (ICR) independent from random allocation to either ticagrelor or aspirin. Of 1859 patients enrolled in the Ticagrelor in CABG trial, 1550 patients (83.4%) received CR and 309 patients (16.6%) ICR. Outcomes were evaluated regarding all-cause mortality, cardiovascular death, myocardial infarction (MI), repeat revascularization, stroke and bleeding within 12 months after CABG. Baseline parameters revealed significant differences regarding clinical presentation (stable angina pectoris: CR 68.9% vs ICR 71.2%, instable angina pectoris: 14.1% vs 7.8%, non-ST elevation MI: 17.0% vs 21.0%, P ˂ 0.01), lesion characteristics (chronic total occlusion: CR 91.3% vs ICR 96.8%, P ˂ 0.01), operative technique [off-pump coronary artery bypass surgery (OPCAB): CR 3.0% vs ICR 6.1%, P ˂ 0.01] and number of utilized grafts (total number of grafts: 2.69/patient vs 2.49/patient, P ˂ 0.001). ICR patients displayed a significantly increased risk of repeat revascularization [hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.16-3.16; P < 0.01] and percutaneous coronary intervention (HR 1.95, 95% CI 1.13-3.35; P < 0.05) within 12 months after CABG. Higher risk for repeat revascularization in ICR patients was independent from random allocation to either ticagrelor or aspirin and persisted after adjustment for baseline imbalances. Patients with ICR presented more stable at the time of admission, but received less grafts, highly likely due to a higher rate of chronic total occlusion lesions and performed OPCAB. Although mortality presented no difference between groups, our results suggest that patients benefit from CR with regard to prevention of repeat revascularization.

Zero-contrast percutaneous coronary intervention for chronic total occlusions guided by intravascular ultrasound with ChromaFlo mode: a case report.

BackgroundContrast agent allergy may result in severe adverse events that prevent the use of percutaneous coronary intervention (PCI) in some patients, especially for those with complex lesions.Case summaryWe describe a 59-year-old man who presented with the multi-vessel disease and suffered from contrast allergy. The patient refused to have coronary artery bypass grafting surgery, thus two-stage PCI procedures without iodinated contrast media were performed after a detailed discussion with the heart team, including a chronic total occlusion (CTO) lesion in the proximal left anterior descending artery. The intravascular ultrasound (IVUS) was used for finding the entry point of the proximal fibre cap, and assessing the lesion, thereby marking the positions of the proximal and distal edges of the stent. After PCI, stent expansion and subtle edge dissection or incomplete apposition were confirmed by IVUS and ChromaFlo imaging. Zero-contrast PCI was done successfully without any complication.DiscussionThis case report illustrates the feasibility and safety of performing CTO-PCI without contrast agent in carefully and well prepared selected patients.

Cystatin C-Based Renal Function in Predicting the Long-Term Outcomes of Chronic Total Occlusion After Percutaneous Coronary Intervention.

Renal function estimated by various biomarkers predicting for adverse cardiovascular events has not been well-identified in received percutaneous coronary intervention (PCI) for chronic total occlusion (CTO), the advanced stages of atherosclerosis. We aim to determine whether the serum cystatin C-based-estimated glomerular filtration rate (eGFR) can have an improved predictive value in patients with CTO lesions undergoing PCI as compared with multiple creatinine-based estimates of kidney function. Six hundred and seventy-one patients received CTO PCI were retrospectively included in the study. The eGFR was calculated by modification of diet in renal disease equation for Chinese (cMDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations at baseline, respectively. Then, the cohort was categorized into three groups according to standard KDIGO kidney stages based on eGFR. The primary endpoint was all-cause mortality, and the secondary endpoint was cardiac death. Strikingly, cystatin C-based eGFR showed a better performance with the greater area being under the receiver operating characteristic (ROC) curve (0.73 for all-cause mortality and 0.73 for cardiac death, separately) and a better assessment for survival free from adverse event across renal levels among four eGFR equations. Compared with eGFR calculated by other formulas, serum cystatin C-based eGFR showed the highest prognostic value for both all-cause mortality (adjusted HR 3.6, 95% CI 1.6–8.1, P = 0.002) and cardiac death (adjusted HR 2.9, 95% CI 1.0–8.1, P = 0.028). Moreover, cystatin C-based eGFR significantly improved the risk reclassification of event with a high value of net reclassification improvement and integrated discrimination improvement. This study may prove that cystatin C-based eGFR is a better predictor of both all-cause mortality and cardiac death than other equations in populations with CTO undergoing PCI.

Impact of chronic total occlusion in non-culprit vessels on long-term survival of patients with acute myocardial infarction

Abstract Background Around 10% of patients with acute myocardial infarction (AMI) have chronic total occlusion (CTO) in non-infarct-related vessels, and they are known to be associated with higher mortality in acute phase. However, its impact on long-term prognosis after discharge remains unclear. Purpose The purpose of this study was to investigate the influence of presenting CTO lesion on long-term prognosis in patients with AMI. Method Consecutive 552 patients with AMI (male 78.3%, age 68±13 years), who had been discharged alive from our hospital, were analyzed. We divided the patients into two groups based on whether they had CTO lesion in a non-infarct-related artery or not: CTO + (n=49) and CTO - (n=503). Results Kaplan-Meier analysis (mean follow-up 1,424 days) revealed that all-cause mortality was significantly higher in CTO + group than in CTO - group (Figure, P&amp;lt;0.001). Cox hazard ratio was 2.740, indicating a higher risk of all-cause death in the CTO + group (95% CI 1.606–4.651, P&amp;lt;0.001). Conclusion Concurrent coronary CTO lesions in non-culprit arteries were associated with increased long-term mortality in patients with AMI. Figure 1 Funding Acknowledgement Type of funding source: None

A contemporary definition of periprocedural myocardial injury after percutaneous coronary intervention of chronic total occlusions

Abstract Background Coronary chronic total occlusion (CTO) recanalization represents the most technically challenging percutaneous coronary interventions (PCI). The complexity harbours a significant increased risk risk for complications with CTO PCI as compared to non-CTO PCI. However there are evidenced biomarker cut-off levels that help to identify those patients at risk for an unfavorable clinical outcome. Objective This study aimed to assess the prognostic impact of postprocedural troponin T increase and mortality in patients undergoing CTO-PCI in order to define the threshold, where procedural related myocardial injury drives mortality. Methods We enrolled a total of 3712 consecutive patients undergoing PCI for at least one CTO lesion and performed comprehensive troponin Tmeasurements 6, 8, and 24 hours after the procedure. All-cause mortality was defined as the primary study endpoint. Results Using spline curve analysis, we observed that a more than 18-fold increase of troponin above the upper reference limit (URL) is significantly associated with mortality. In the Cox regression analysis we observed a crude hazard ratio (HR) of 2.32 (95% CI 1.83–2.93, P&amp;lt;0.001) for a ≥18fold increase compared to patients with post-procedural troponin increase &amp;lt;18-fold of the URL.Results remained virtually unchanged after bootstrap- or clinical confounder-based adjustment. Conclusion This large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in CTO patients. We could define a threshold for procedure related myocardial injury in CTO patients that differ non- CTO patients and may help guide the postprocedural clinical care in this high risk patient population. Figure 1 Funding Acknowledgement Type of funding source: None

Fate of lumen size in distal coronary segment following successful chronic total occlusion recanalization

BackgroundRestoration of anterograde blood flow leads to alterations in vascular wall stress that may influence lumen size distal to chronic total occlusion (CTO) lesions. We sought to assess changes in lumen diameter of segments distal to the stent segment of successfully recanalized CTO. MethodsWe analyzed 507 consecutive CTO cases with stent implantation that underwent follow-up angiography at a single high-volume center (mean follow-up of 13.5 months). Segments ≤40 mm distal to the stent edge were analyzed using quantitative coronary angiography. ResultsAt follow-up, lumen diameters significantly increased; diameter changes of 0.26 ± 0.47 (percent diameter change of 18.2%) at 5 mm distal, mean lumen diameter changes of 0.23 ± 0.35 (14.3%) and minimal lumen diameter changes of 0.22 ± 0.80 (24.7%) (all p < 0.001). Lumen enlargement was similar between visually shrunken and stenosed vessels (degree of stenosis ≥20% with luminal irregularities) distal to stents; 5 mm distal (0.32 ± 0.48 vs. 0.30 ± 0.48, p = 0.76), mean lumen diameter changes (0.26 ± 0.37mm vs. 0.26±0.33 mm, p = 0.94), minimal lumen diameter changes (0.28 ± 0.43 mm vs. 0.22 ± 1.30 mm, p = 0.48). There was no association between degree of in-stent narrowing and changes in distal lumen diameter (Spearman r = −0.02, p = 0.59). Multivariate logistic regression for the predictors of greater lumen enlargement indicated that patients with left ventricle dysfunction (ejection fraction ≤45%) had greater enlargement [odds ratio (OR): 2.53, 95% confidence interval (CI): 1.23–5.23, p = 0.01]. Conversely, a low hematocrit (male <40%, and female <35%) was associated with attenuated lumen enlargement (OR: 0.68 95% CI: 0.47–0.98; p = 0.04). ConclusionsLumen diameter distal to CTO lesions significantly increased following successful revascularization, regardless of diseased status of the distal bed or degree of in-stent narrowing. These findings implicate appropriate determination of stent size, stent coverage length, as well as management strategies of distal vessels.

Long-term follow-up of therapeutic efficacy of everolimus-eluting bioresorbable vascular scaffold in comparison to everolimus-eluting stent in treatment of chronic total occlusion guided by intracoronary imaging

BackgroundWe hypothesized that 1st generation everolimus-eluting bioresorbable vascular scaffold (BVS) stent associated with less complication and less restenosis rate than everolimus-eluting stent (EES) in chronic total occlusion (CTO) recanalization guided by intracoronary imaging. Therefore, we aimed to assess the safety and performance of BVS stent in CTO revascularization in comparison to EES guided by intracoronary imaging.Our prospective comparative cross-sectional study was conducted on 60 CTO patients divided into two groups according to type of stent revascularization: group I (EES group): 40 (66.7%) patients and group II (BVS group): 20 (33.3%) patients. All patients were subjected to history taking, electrocardiogram (ECG), echocardiography, laboratory investigation, stress thallium study to assess viability before revascularization. Revascularization of viable CTO lesion guided by intracoronary imaging using optical coherence tomography (OCT). Then, long-term follow-up over 1 year clinically and by multi-slice CT coronary angiography (MSCT). Our clinical and angiographic endpoints were to detect any clinical or angiographic complications during the follow-up period.ResultsAt 6 months angiographic follow-up, BVS group had not inferior angiographic parameters but without statistically significant difference (p = 0.566). At 12 months follow-up, there was no difference at end points between the two groups (p = 0.476).No differences were found at angiographic or clinical follow-up between BVS and EES.ConclusionThis study shows that 1st generation everolimus-eluting BVS is non-inferior to EES for CTO revascularization. Further studies are needed to clearly state which new smaller footprint BVS, faster reabsorption, magnesium-based less thrombogenicity, and advanced mechanical properties is under development. We cannot dismiss the efficacy and safety of new BVS technology.Trial registrationZU-IRB#2498/3-12-2016 Registered 3 December 2016, email: IRB_123@medicine.zu.edu.eg

Effectiveness and long-term outcomes of different crossing strategies for the endovascular treatment of iliac artery chronic Total occlusions

BackgroundThe iliac occlusive disease is usually treated with endovascular procedures in recent years. The effectiveness of different crossing approaches for these occlusions is not precisely known. We performed a retrospective study to explore the optimal crossing approach (antegrade versus retrograde) for iliac artery chronic total occlusions (CTOs) and to examine the long-term outcomes.Materials and methodsWe performed a study on 107 patients (116 iliac occlusive lesions, mean age 64.0 ± 11.1, 88 men) who underwent an iliac CTO endovascular intervention attempted with the use of both crossing strategies but were managed with one final crossing approach between August 2012 and August 2018. Baseline data, procedural characteristics, and outcomes were described. A Cox proportional hazard model and Kaplan-Meier method were developed to assess the differences in the two crossing approaches in terms of the 1-year and 5-year primary patency rates, target lesion revascularization (TLR) and major adverse limb events (MALEs).ResultsCommon iliac artery (CIA) lesions were more likely to be crossed successfully in the retrograde direction (6.8% for antegrade vs. 20.9% for retrograde, p = 0.005), while lesions in the CIA/ external iliac artery (EIA) were more prone to be crossed successfully in the antegrade direction (58.9% for antegrade vs. 39.5% for retrograde, p = 0.016). There were no significant differences in the crossing approach for EIA lesions between the two groups. The two crossing approaches were associated with similar estimates of 1- and 5-year primary patency, TLR and MALE rates.ConclusionThe antegrade approach was associated with a higher rate of successful crossing in CIA/EIA CTO lesions, while the CIA-only CTOs were more likely to be crossed successfully with the retrograde approach.

Efficacy and safety of balloon-assisted microdissection with Sapphire® II 1.0-mm balloon in balloon-uncrossable chronic total occlusion lesions.

ObjectiveEarlier studies have shown that the balloon-assisted microdissection (BAM) technique is feasible using a 1.2- to 1.5-mm small balloon in balloon-uncrossable chronic total occlusion (CTO) lesions. This study was performed to assess the efficacy and safety of the BAM technique with a Sapphire® II 1.0-mm balloon.MethodsIn this retrospective study, patients undergoing percutaneous coronary intervention for CTO were consecutively screened for balloon-uncrossable CTO lesions using BAM with the Sapphire® II 1.0-mm balloon. The patients’ clinical and angiographic characteristics and procedural outcomes were collected for analyses.ResultsTwenty-four balloon-uncrossable CTO lesions were identified. Most of the CTO lesions were located in the right coronary artery, followed by the left anterior descending artery and left circumflex artery. The mean Japanese Multicenter CTO Registry (J-CTO) and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) scores were 1.96 and 1.38, respectively. The total technical success rates were 91.6% (22/24) and 75.00% (18/24) for the lesions that were successfully treated with BAM. No patients developed major complications with the exception of one patient who developed a femoral hematoma.ConclusionBAM with the Sapphire® II 1.0-mm balloon may be an effective and safe technique for balloon-uncrossable CTO lesions.

Further advancement in the percutaneous revascularization of coronary chronic total occlusions: the redefined "Minimalistic Hybrid Approach" algorithm

A careful angiographic assessment of a chronic total occlusion (CTO) is essential for optimal procedural planning. In the classic hybrid approach, the insertion of two guiding catheters at the beginning of the intervention is recommended. This is fundamental to perform simultaneous double injection, to achieve complete visualization of the coronary circulation and to choose the best starting strategy between antegrade wire escalation (AWE), antegrade dissection and re-entry (ADR) and the retrograde techniques (retrograde wire escalation [RWE] and retrograde dissection and re-entry [RDR]). In the hybrid algorithm the set-up is the same, regardless of the chosen first strategy, and therefore routinely uses double access. Because revascularizations of CTOs commonly require large bore catheters (7-8 French) to ensure high back-up support, the femoral arterial access is preferred by most of the operators. However, the use of a double access, large introducer sheaths and femoral approach are associated with a greater risk of access-related complications and even the occurrence of major adverse cardiovascular events. We have previously proposed an algorithm, called "minimalistic hybrid approach," which aims to limit the routine use of dual injection, and to favor the use of trans-radial access and smaller (6-7 French) guiding catheters. In this algorithm the chosen starting strategy depends on the complexity of the lesion assessed by J-CTO Score and on the presence of favorable contralateral interventional collateral circulation. However, this novel algorithm proved to have some limitations, such as the non-specific evaluation of CTOs with ipsilateral collateral circulation and the too arbitrary choice of the starting strategy based on a J-CTO Score cut-off. These considerations led to the development of an "updated" minimalistic hybrid approach algorithm that considers the type of collaterals (ipsilateral or contralateral) and the a-priori choice of the hybrid technique, with the highest chance of success in that specific CTO lesion (independently from the J-CTO Score). One important aspect that makes this algorithm unique is its "dynamicity:" not only for the technique to be used, as in the classic hybrid algorithm (shifting between AWE, ADR, RWE and RDR), but also for the set-up, with access site and French size to be adapted during the PCI to the technique adopted. We believe that this novel approach could further improve the safety of CTO-PCI without losing its current efficacy.