Complex Chronic Total Occlusion Lesions Research Articles

Intravascular Lithotripsy versus Rotational Atherectomy in Coronary Chronic Total Occlusions: Analysis from the PROGRESS-CTO registry

There is limited comparative data on the use of plaque modification devices during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We compared intravascular lithotripsy (IVL) with rotational atherectomy (RA) for lesion preparation in patients who underwent CTO PCI across 50 US and non-US centers from 2019 to 2024. Among 15,690 patients who underwent CTO PCI during the study period, 436 (2.78%) underwent IVL and 381 (2.45%) RA. Patients treated with IVL had more comorbidities and more complex CTO lesions. Antegrade wiring was the most commonly used initial and successful crossing strategy for lesions treated with both IVL and RA, although the retrograde approach was more frequently employed in IVL cases. Procedure and fluoroscopy times, as well as air kerma radiation doses and contrast volumes, were higher in patients treated with RA compared with IVL. There were no significant differences between the groups in technical success (97.2% vs. 95.3%, p=0.20), procedural success (94.7% vs. 91.8%, p=0.14), and in-hospital major adverse cardiac events (MACE) (3.0 % vs. 4.2%, p=0.47). However, coronary perforations were more frequent in patients undergoing RA (9.5% vs. 3.2%, p<0.001). Multivariable logistic regression analysis revealed that IVL compared with RA was not independently associated with technical success, procedural success, or in-hospital MACE. In patients undergoing CTO PCI, IVL is associated with similar in-hospital MACE, technical success, and procedural success, but lower incidence of coronary perforation, compared with RA.

Antegrade versus Retrograde Approach for Recanalization of Ostial or Stumpless Coronary Chronic Total Occlusion.

This research aimed to evaluate the procedural and in-hospital clinical outcomes of percutaneous coronary intervention (PCI) for ostial or stumpless chronic total occlusion (CTO) utilizing both the antegrade-only and retrograde approaches. A comprehensive retrospective examination was conducted on the procedural and in-hospital clinical outcomes of 89 consecutive patients subjected to ostial or stumpless CTO PCI at our institution between April 2015 and October 2022. The antegrade-only technique demonstrated a superior technical success rate (92.0% vs 71.9%, p = 0.041) and procedural success rate (92.0% vs 68.8%, p = 0.022) in comparison to the retrograde approach (RA). The RA group presented a notably elevated Japanese-CTO (J-CTO) score relative to the antegrade-only approach group (2.45±0.73 vs 1.64±0.70, p < 0.001). The antegrade-only approach group manifested an increased frequency of microchannels at the proximal stump relative to the RA group (56.0% vs 10.9%, p < 0.001). In-hospital major adverse cardiac events (MACE) and in-hospital myocardial infarction (MI) were observed more prevalently in the RA group (18.8% vs 0, p = 0.003; 15.6% vs 0, p = 0.008; respectively). A J-CTO score below 2 and the manifestation of microchannels at the proximal stump were identified as predictors for successful antegrade-only approach PCI for ostial or stumpless CTO (OR: 2.79 [95% CI: 1.92-5.03, P =0.003]; OR: 2.89 [95% CI: 1.32-6.03, P =0.001]; respectively). Relative to RA PCI for ostial or stumpless CTO, the antegrade-only approach is utilized for less complex CTO lesions and is associated with a diminished probability of in-hospital MACE.

Procedural outcomes of chronic total occlusion percutaneous coronary intervention in patients with dissection and reentry versus wire escalation techniques: a meta-analysis.

The procedural safety of dissection and reentry (DR) techniques in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains controversial, when compared with conventional wire escalation (WE) techniques. The meta-analysis was performed to evaluate the impact of DR techniques vs. WE techniques on periprocedural outcomes in patients with CTO undergoing PCI. Studies were searched in electronic database from inception to December 2018. Results were pooled using random effects model and fixed effects model. The pooled analyses revealed that DR techniques increased risks of periprocedural complications in patients with CTO PCI, including higher coronary perforation rate [risk ratio (RR) = 2.10, 95% confidence interval (CI) 1.24-3.55], periprocedural myocardial infarction (RR = 1.85, 95% CI 1.23-2.78), branch occlusion (RR = 2.69; 95% CI 1.92-3.77) and coronary hematoma (RR = 3.06; 95% CI 2.45-3.82) detected by intravascular ultrasound, when compared to those with WE techniques. However, DR techniques were more applied in patients with higher complexity CTO lesions, which was evidenced by higher J-CTO score [standard mean differences (SMD) = 0.71, 95% CI 0.51-0.91] and longer fluoroscopy time (SMD = 0.93, 95% CI 0.70-1.16), that may explain the higher complications rates in the DR techniques group as compared with WE techniques. The present meta-analysis suggests that the DR technique is relatively frequently used during contemporary CTO PCI, especially for challenging more complex CTO lesions. However, it is associated with higher, yet acceptable, rates of periprocedural adverse events as compared with a conventional WE strategy. Further refinement of DR techniques and evidence from large RCTs is needed to define the optimal role of DR in hybrid CTO PCI.

A novel real-time intravascular ultrasound double-lumen microcatheter for recanalization of chronic total occlusion: a case report

BackgroundChronic total occlusion revascularization remains a challenging problem because of its complexity. We present a case of a patient with chronic total occlusion who was successfully revascularized with the use of a new device called a real-time intravascular ultrasound double-lumen microcatheter.Case presentationA 58-year-old East Asians woman presented to our hospital with a complaint of recurrent chest pain of 5 months’ duration. Angiography revealed chronic total occlusion of the right coronary artery from the right coronary artery ostium to the ostia of the posterolateral and posterior descending branches. A guidewire was passed to the distal right coronary artery but went into the false lumens at the posterior descending and posterolateral ostia after use of the antegrade and retrograde approaches. Hence, we used the new device to pass through the subintimal right coronary artery space with reentry into the true lumen before the posterior descending and posterolateral ostia. A stent was successfully deployed at the posterior descending and posterolateral ostia, and the final result was excellent.ConclusionsThis device was useful for finding the entry point and for reentry into the true lumen of a chronic total occlusion. It may be a valuable tool for recanalization of complex chronic total occlusion lesions.

Retrograde Versus Antegrade Approach for Coronary Chronic Total Occlusion in an Algorithm-Driven Contemporary Asia-Pacific Multicenter Registry: Comparison of Outcomes

The use of a retrograde approach and algorithm-driven CTO (chronic total occlusion) percutaneous coronary intervention (PCI) has become widespread, and many registries have reported good results. This study established a new algorithm and applied it to current CTO practice and collected a CTO registry to document the results. It compared the outcomes of a retrograde versus antegrade approach in a contemporary multicentre CTO registry. Between 1 January 2016 and 31 December 2016, consecutive patients who underwent CTO PCI performed by eight high-volume CTO operators were included in a registry. During this period, 485 patients with 497 CTOs were treated with technical and procedural success rates of 93.8% and 89.9%, respectively. Antegrade and retrograde technical success was 95.9% and 91.2% (p = 0.03), respectively. Procedural success for antegrade and retrograde was 94.4% and 84.6%, respectively (p < 0.001). The pure retrograde success rate was 80% and pure antegrade success rate was 75%. Technical success in different Japanese Chronic Total Occlusion (JCTO) score groups was 100% (JCTO 0), 96.2% (JCTO 1), 95.3% (JCTO 2), and 92.5% (JCTO ≥ 3), with no statistical difference in success rates between different JCTO scores. In-hospital major adverse cardiac event (MACE) was 3.8% and more common in the retrograde group (6.6% vs 1.5%). The retrograde approach, when used by experienced operators who have been well trained in retrograde approach, can produce higher retrograde success in complex CTO lesions. The use of an algorithm approach can improve procedural efficiency, reduce contrast and radiation dosage, and reduce the time spent in failure mode. These tools remain vital to the development of future CTO PCI.

Chronic Total Occlusion Interventions: Update on Current Tips and Tricks.

To summarize novel techniques and developments in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Using an algorithmic, step-by-step approach can help overcome several complex CTO lesions subsets, such as proximal cap ambiguity, ostial location, in-stent occlusion, bifurcations, balloon uncrossable and undilatable lesions. Similarly, an algorithmic approach can help prevent and optimally treat CTO PCI-related complication, such as perforation, radiation, and contrast-induced nephropathy. Continual update and reassessment of each operator's algorithm for performing CTO PCI can lead to improved outcomes.

Intravascular ultrasound guided wiring re-entry technique for complex chronic total occlusions.

The successful recanalization rate of chronic total occlusion (CTO) lesions without retrograde collaterals available is always low. Intravascular ultrasound (IVUS) may be useful to guide the subintimal guidewire to re-enter the true lumen. We evaluated the clinical feasibility and efficacy of the IVUS-guided wiring re-entry technique for these complex CTO lesions. Twenty consecutive patients (19 male, mean age: 65.3 ± 12.8 years) with both failed antegrade and retrograde approaches were enrolled. The IVUS catheter was introduced into the subintimal space to identify the entry point into the subintimal space, and guide another stiff wire to re-enter the true lumen with the adjacent side-branch or first wire as markers, or using IVUS-guided parallel wire technique. The entry point into the subintimal space was identified by IVUS in all cases, and the IVUS-guided wiring re-entry technique succeeded in 17 cases (85%). No procedure-related complication was noted except one case of delayed cardiac tamponade due to the wire perforation. During the mean follow-up period of 1.9 ± 1.3 years, there was no adverse cardiac event, except one patient died of the complication of cardiac transplantation. The IVUS-guided wiringre-entry technique might be feasible and safe for the recanalization of complex CTO lesions.

Crossing techniques and devices in femoropopliteal chronic total occlusion intervention.

Chronic total occlusions (CTO) are common in patients with symptomatic peripheral arterial disease. Endovascular CTO intervention remains a challenging endeavor for interventionalists, but is being increasingly considered as a plausible alternative to surgical revascularization, even for complex CTO lesions. We review common endovascular techniques using antegrade, retrograde and transcollateral approaches in femoropopliteal CTO intervention. In addition, we review the current literature on the utility, efficacy, and safety of novel crossing and re-entry devices in femoropopliteal CTO interventions.

Everolimus-eluting bioresorbable vascular scaffolds for treatment of complex chronic total occlusions.

Bioresorbable vascular scaffolds (BVS) represent a novel therapeutic option for the treatment of coronary artery diseases. The objective of this study was to evaluate the feasibility of BVS implantation in complex chronic total occlusions (CTO). The present report is a multicentre registry evaluating results after BVS deployment in challenging CTO lesions, defined as J-CTO score ≥2 (difficult or very difficult). A total of 105 patients were included in the present analysis. The mean J-CTO score was 2.61 (difficult 52.4%, very difficult 47.6%). Device success and procedural success rates were 98.1% and 97.1%, respectively. The retrograde approach was used in 25.7% of cases. After wire crossing, predilatation was performed in all cases with a mean predilatation balloon diameter of 2.73±0.43 mm. The mean scaffold length was 59.75±25.85 mm, with post-dilatation performed in 89.5% of the cases and a mean post-dilatation balloon diameter of 3.35±0.44 mm. Post-PCI minimal lumen diameter was 2.50±0.51 mm and percentage diameter stenosis 14.53±10.31%. At six-month follow-up, a total of three events were reported: one periprocedural myocardial infarction, one late scaffold thrombosis and one additional target lesion revascularisation. The present report suggests the feasibility of BVS implantation in complex CTO lesions, given adequate lesion preparation and post-dilatation, with good acute angiographic results and midterm clinical outcomes.

Does Percutaneous Coronary Interventions of Coronary Chronic Total Occlusions to Patients with Prior Coronary Artery Bypass Graft Surgery Have Poorer Pocedural Outcome?

Objectives: This study aimed to investigate procedural outcomes of Percutaneous Coronary Intervention (PCI) for Chronic Total Occlusion (CTO) in patients with prior Coronary Artery Bypass Graft (CABG).Background: Patients with prior CABG often have more comorbidities, complex coronary anatomy, and poorer outcomes than those without prior CABG. Success of PCI for CTO may be more challenging in patients with prior CABG.Methods: We evaluated clinical characteristics and procedural outcomes in 317 consecutive patients undergoing CTO-PCI, and compared the results between patients with (n = 70) and without prior CABG (n = 247).Results: Patients with prior CABG were older and had more coronary artery disease risk factors than those without prior CABG. CTO-PCI was more often performed in the right coronary artery. Patients with prior CABG had significantly higher mean J-CTO score (2.3 ± 1.2 vs. 1.7 ± 1.3, P = 0.0019). Detailed investigation of the characteristics of J-CTO score indicated the greatest impact of the presence of calcifications. Patients with prior CABG were treated more frequently with the retrograde approach (41.4% vs. 17.8%, P = 0.0004) and had longer fluoroscopic times, higher radiation dose, and more contrast administration. Technical and procedural success were achieved in 80.0% vs. 85.0% (P = 0.35) and 78.6% vs. 83.6% (P = 0.38), respectively; these differences were not significant.Conclusions: CTO-PCIs of patients with prior CABG did not indicate poorer procedural outcome. However, patients with prior CABG had more complex CTO lesions, and CTOPCIs of them were required higher use of the retrograde approach.

Overcoming Difficult Chronic Total Occlusion: Increasing the Applicability of Endovascular Intervention to Patients with Challenging Re - entry: Double Balloon Technique in Crossing Challenging Chronic Total Occlusions

Context: Chronic total occlusions (CTOs) sometimes are a challenge for endovascular intervention, especially in developing countries where new devices used to cross CTOs are either unavailable or too expensive. Using basic endovascular tools remains the only solution in such cases when patients were at high risk for open surgical intervention. We present our experience of using double balloon technique to cross CTO lesions in the femoropopliteal segment after failure of known traditional techniques, i.e. intraluminal, subintimal angioplasty, and subintimal arterial flossing with antegrade–retrograde intervention (SAFARI technique). We looked for technical success of double balloon technique in such difficult CTO. Aims: To assess the safety and applicability of double balloon technique in crossing long and complex CTOs lesions, where new crossing re-entry devices are unavailable. Subjects and Methods: This is a retrospective study to look into cases between November 2013 and October 2015, in Kasr Ani Hospital, Cairo University, Egypt. Results: The success rate of the technique was 100%. Conventional Methods: Intraluminal, subintimal angioplasty, and SAFARI technique for crossing CTOs in the femoropopliteal territory were used in 350 lesions, but it failed in 30 where double balloon technique was used. The technical success rate of the technique was 100%. Conclusions: Double balloon technique was safe and cheap. It should replace the use of new re-entry devices keeping them only in bail-out cases after the failure of this technique.

Which parameters are important before attempting chronic total occlusions recanalization?

Which parameters are important before attempting chronic total occlusions recanalization?

The learning curve in treating coronary chronic total occlusion early in the experience of an operator at a tertiary medical center: The role of the hybrid approach.

Treatment of chronic total occlusion (CTO) is complex and has a low adoption rate by interventional cardiologists. The introduction of the hybrid approach has provided a systematic step-by-step approach to treat complex CTO lesions with a high success rate. We describe the overall experience with the use of the hybrid approach of a non-CTO operator and analyze differences in the procedural and long term outcomes before and after the initial 30 cases performed. A total of 67 unselected, consecutive patients (68 lesions) underwent PCI of a CTO between January 2012 and June 2013 by a non-CTO operator. Patients were followed up for 1year using office and hospital medical records and death certificates. Cases were divided into the first consecutive 30 patients and compared to the subsequent 37 patients. The primary endpoint was acute procedural success defined as residual narrowing of ≤30% with no major adverse events. Secondary endpoints included the independent outcomes of death, major bleeding, perforations with cardiac tamponade, acute stent thrombosis (ST), target lesion revascularization (TLR) and target vessel revascularization (TVR). Descriptive analysis was performed on all variables. Univariate analysis was used to compare both groups. Baseline characteristics were as follows: mean age 63.9±10.6years, males 80.6%, diabetes 41.8%, de novo lesions 100%, ejection fraction 49.9±13.8%, CTO length 76.9±45.7mm, number of drug eluting stents per CTO 2.8±1.6 (median 3), contrast use 397±161.3ml, fluoroscopy time 51±32min and procedure time 134.3±74.7min. Lesions were crossed using an antegrade approach in 70.6% and a combined retrograde/antegrade approach in 29.4%. Crossing was intraluminal in 83.8% and subintimal in 16.2%. Acute procedural success was 95.5%. MAE included pericardial effusion with tamponade in 4.5%. On follow-up, TLR occurred in 6.6% of patients and TVR in 13.1%. There were no definite ST, one (1.6%) probable ST and one (1.6%) possible ST. Cardiac death occurred in 4.8% and non-cardiac death 1.6%. When comparing early experience (first 30 cases) with subsequent one, there were no differences in CTO length (60±47.6mm vs 83.2±43.7mm, p=0.206) or coronary distribution of the CTO. The number of drug eluting stents used per CTO (2.6±1.7 vs 3.0±1.5, p=0.289), contrast use (401±141.2ml vs 393.7±177.8ml, p=0.856), fluoroscopy time (48.9±25.6min vs 52.9±36.5min, p=0.617), or procedure time (116.8±48.6min vs 148.5±88.7min, p=0.068) were statistically similar between the 2 groups. Less crossing catheters were used (1.1±1 vs 0.6±0.7, p=0.024) and more lesions were crossed via antegrade approach after the initial experience (antegrade crossing: 53.3% vs 84.2% respectively, p=0.008). There was numerically more procedural success after the initial experience (90 vs 100%, p=0.085). MAE, TLR and TVR were similar on 1year follow-up. A high success rate was seen using the hybrid approach to treat CTO by a non-CTO operator. Although less crossing catheters were used and more lesions were treated via the antegrade approach after the initial experience, procedural and long term outcomes were otherwise similar between the early versus the late experience.

Utility of the SYNTAX score in predicting outcomes after coronary intervention for chronic total occlusion.

Chronic total occlusion (CTO) lesions are a challenging issue. When dealing with complex CTO lesions in patients undergoing percutaneous coronary intervention (PCI), it is important to evaluate not only the CTO lesion itself but also atherosclerotic lesions of the whole coronary artery tree. The utility of the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery Trial) score in patients with CTO undergoing PCI is unclear. This retrospective study included 304 consecutive patients with CTO lesions who underwent PCI. Primary endpoints were procedural failure and major adverse cardiac events (MACE) within 30days. The SYNTAX and J-CTO (Multicenter CTO Registry in Japan) scores were assessed before the procedures, and patients were divided into two groups according to SYNTAX criteria: high (> 22; n = 158) and low (≤ 22; n = 146) SYNTAX scores. Procedural success was achieved in 252 patients (82.9 %). Patients with a high SYNTAX score had significantly lower procedural success than those with a low SYNTAX score (74.7 % versus 91.8 %, p < 0.0001). There were 13 MACE (8.2 %) in patients with high SYNTAX scores and two MACE (1.4 %) in those with low scores. The SYNTAX and J-CTO scores had odds ratios of 3.33 (95 %CI, 1.44-7.74) and 3.64 (95 %CI, 1.24-10.66) for procedural failure. A higher SYNTAX score (> 22) was also an independent predictor of 30-day MACE after PCI (odds ratio = 4.80, 95 %Cl 1.03-22.42). The SYNTAX score is predictive of procedural failure, as is the J-CTO score. Furthermore, a higher SYNTAX score is strongly associated with an increased risk of 30-day MACE. The SYNTAX score is useful for clinical decision making when treating patients with complex CTO lesions.

Recanalization of Complex Coronary Chronic Total Occlusions Using High‐Frequency Vibrational Energy CROSSER Catheter as First‐Line Therapy: A Single Center Experience

Several studies have illustrated the safety and the procedural outcome of high-frequency vibrational energy in guidewire refractory chronic total occlusions (CTOs). To evaluate the advantage of high-frequency vibrational energy device (CROSSER Catheter) use in coronary complex CTO revascularization as primary strategy. CROSSER was used as a primary approach if four or more unfavorable angiographic features were observed in the CTO lesions. From May 2007 to February 2009, a CTO percutaneous intervention attempt was performed in 178 lesions of 171 patients (60.1 +/- 8.9 age with 49.4 +/- 7.2% in ejection fraction). Among these, the CROSSER was used in 46 complex CTO lesions of 45 patients (25.8% of cases) and in the remaining cases, typical CTO percutaneous coronary intervention techniques were employed. Clinical success was 84.8% in CROSSER group. Moreover, in the CROSSER group, no periprocedural myocardial infarction, perforation, or 30 days MACE was observed. In addition, the use of CROSSER was associated with lower time of procedure, time of fluoroscopy, and contrast load administration as compared with conventional techniques [88 +/- 27 minutes vs 109 +/- 38 minutes (P = 0.045), 39 +/- 12 minutes vs 50 +/- 27 minutes (P = 0.032), and 334 +/- 122cc vs 408 +/- 198cc (P = 0.05), respectively]. In the present study, the CROSSER System was safe and obtained a high rate of success in complex CTO similar to conventional dedicated guidewire techniques for noncomplex CTO; however, the CROSSER Catheter obtained CTO recanalization with lower contrast load administration, less time of procedure, and lower fluoroscopy exposure.