Coronary Intervention For Chronic Total Occlusion Research Articles

Implementing a minimally invasive approach (combining radial approach, small guiding catheters and minimization of double access) for coronary chronic total occlusion intervention according to the hybrid algorithm: The Minimalistic Hybrid Algorithm

Percutaneous recanalization of coronary chronic total occlusions (CTOs) traditionally relies on the use of dual access and large bore catheters, with trans-femoral approach adoption in most of the cases. Aim of this manuscript is to describe an alternative algorithm, that we called “Minimalistic Hybrid Algorithm”, in order to minimize the use of double access, large bore catheters, and femoral approach thus reducing patient's discomfort and possibly procedural complications. This algorithm can be interpreted as an evolution of the classic “Hybrid Algorithm” and requires the operator to be confident with all techniques known in this conventional algorithm. Indeed, all possible techniques and approaches of the conventional hybrid approach to treat CTOs are included in a novel diagram for procedural strategy, which offers an alternative sequence of steps to limit, whenever possible, the invasiveness of the procedure. After dividing the cases in “simple” or “complex” CTO lesions according to the available complexity scores and to the “feeling”, knowledge and expertise of the operator, a systematic description of the procedural steps is provided. This includes antegrade and retrograde approaches, as well as sub-intimal and intra-luminal techniques, in order to maintain the simpler single-catheter transradial strategies in the first line for the simple CTO, and the adoption of more complex, double access and transfemoral ones in the further steps. The minimalistic hybrid algorithm herein described is a possible alternative sequence of steps in the setting of CTO recanalization, with the potential of limiting the use of double access, large bore catheters, and femoral approach.

Donor artery stenosis interactions with diastolic blood pressure on coronary collateral flow in type 2 diabetic patients with chronic total occlusion

BackgroundWe investigated whether and to what extent stenosis of predominant collateral donor artery (PCDA) affects coronary collateral flow in relation to blood pressure (BP) in type 2 diabetic patients with chronic total occlusion (CTO).MethodsCollateral flow index (CFI) as derived from intracoronary pressure distal to occluded segment and mean aortic pressure in 220 type 2 diabetic patients and 220 propensity score matched non-diabetic controls undergoing percutaneous coronary intervention for CTO. The severity of PCDA stenosis was graded according to lumen diameter narrowing.ResultsCFI decreased stepwise from mild to severe stenosis of the PCDA and was lower in diabetic patients with moderate or severe PCDA stenosis than in non-diabetic controls (0.36 ± 0.10 vs. 0.45 ± 0.08, P < 0.001; 0.29 ± 0.09 vs. 0.35 ± 0.08, P = 0.008). When the PCDA was mildly stenotic, CFI increased initially along with a reduction in diastolic BP, and decreased when diastolic BP was below 60 mmHg in diabetic patients (0.38 ± 0.16 vs. 0.57 ± 0.09, P < 0.001). In the presence of moderate PCDA stenosis, diabetic patients had significantly lower CFI compared to non-diabetic controls, with a relative reduction of 19.8% at diastolic BP 70–79 mmHg, 28.2% at 60–69 mmHg and 38.2% below 60 mmHg (all P < 0.05). A severe PCDA stenosis resulted in a more pronounced decrease in CFI, with a relative reduction of 37.3% for diabetics compared to non-diabetics when diastolic BP was below 60 mmHg (P = 0.050).ConclusionsIn the setting of CTO, donor artery stenosis confers greater risk for reduced coronary collateral flow when diastolic BP is decreased. Even a moderate stenosis in the PCDA may be associated with lower collateral flow as diastolic BP decreases below 80 mmHg in type 2 diabetic than in non-diabetic patients.

Coronary Chronic Total Occlusion (CTO): A Review.

Coronary artery chronic total occlusions (CTO) are frequently encountered during coronary angiography; however percutaneous recanalization has historically been technically challenging and an important determinant for referral to coronary artery bypass surgery or for medical therapy alone. Recent advances in interventional equipment and innovative approaches to crossing CTO have significantly increased the success rate of percutaneous treatment. Although there is only one relevant randomized control trial (RCT) performed to date, several large, nonrandomized studies have consistently reported improvement in clinical outcomes, including improved survival and relief of angina, when successful percutaneous treatment of CTO was compared with unsuccessful revascularization. These positive observational results have encouraged the initiation of several RCTs which will provide more robust evidence on clinical outcomes of CTO-PCI compared with guideline-directed medical therapy (GDMT) alone.

First report of the use of long-tapered sirolimus-eluting coronary stent for the treatment of chronic total occlusions with the hybrid algorithm.

Coronary chronic total occlusions (CTO) usually coexist with diffusely diseased coronary segments proximal and/or distal to the CTO segment. During percutaneous treatment of CTO, multiple overlapping stents are often needed to treat these long lesions. Aim of this study is to report the first use of long, tapered coronary sirolimus-eluting stents (SES) in this setting. This is a retrospective analysis of 100 consecutive patients undergoing CTO recanalization following the hybrid algorithm. Procedural success rate was 89% (11 failures). Among the successful cases, "conventional" drug-eluting stents(DES) were used in 40(44.9%) patients, while in 49(55%) patients long-tapered SES were attempted with a success rate of 98% (1 cross-over to regular stents). Total stent length in the long-tapered DES group was higher compared to the "conventional" stenting group (76 ± 28 mm vs 46 ± 22 mm, P < .001), with a similar total number of stent (1.6 ± 0.8 vs 1.9 ± 0.8). At quantitative coronary analysis, proximal and distal segment involvement was more extended in patients undergoing long-tapered stenting, with longer overall lesion length. No differences in periprocedural complications and clinical outcomes at a mean follow-up of 303 ± 179 days were observed. The use of long tapered coronary DES is technically feasible and safe for the percutaneous treatment of CTOs, especially for patients presenting with long lesions.

Interventional Management of "Balloon-Uncrossable" Coronary Chronic Total Occlusion: Is There Any Way Out?

It has been estimated that coronary chronic total occlusion (CTO) is encountered in 15 to 20% patients referred for coronary angiography (CAG). The success of percutaneous coronary intervention (PCI) of CTO can be attributed to the vast array of hardware that has now become available and also to the vastly enhanced operator expertise. It is however realistic to state that despite the tremendous increase in the rate of success, there then comes a subset of CTO where PCI attempts fail. The reason for such failures given that other variables remain constant is the inability to cross the CTO lesion. This can be due to a failure to cross the lesion with a guide wire (despite guide wire escalation). The second cause of failure is the inability to cross the lesion with a balloon (balloon-uncrossable [BU] CTO). This can occur despite the successful placement of a guidewire in the distal true lumen. The BU lesions contribute 2% to 10% of CTO PCI failure cases. The author attempts to present a creative solution to assist crossing such lesions.

TCT-468 One-year Clinical Outcomes of Successful Coronary Chronic Total Occlusion Intervention in Patients with Acute Coronary Syndrome; From the Korean, Nationwide, Multicenter CTO (K-CTO) Registry

Chronic total occlusion (CTO) intervention remains challenging because of the limited procedural success rate and higher target failure. Detailed real-world data on safety and efficacy of CTO intervention in acute coronary syndrome (ACS) patients from multicenter registry are limited. Korean

The Demographic and Clinical Profile of Patients Undergoing Coronary Chronic total Occlusion (CTO) Intervention in a teaching hospital in Kerala

The Demographic and Clinical Profile of Patients Undergoing Coronary Chronic total Occlusion (CTO) Intervention in a teaching hospital in Kerala

Everolimus- versus zotarolimus-eluting stent following percutaneous coronary chronic total occlusion intervention

BackgroundAlthough studies have demonstrated comparable efficacy and safety profiles of everolimus- and zotarolimus-eluting stents (EES and ZES, respectively) for a broad spectrum of coronary artery diseases, there is paucity of data concerning their safety and efficacy for coronary chronic total occlusions (CTOs). This study compared the clinical performance of EES and ZES following successful percutaneous coronary intervention for CTOs. MethodsThe cohort included 539 consecutive CTO patients who underwent successful PCI using EES (n=313) and ZES (n=226) between September 2006 and August 2014. The primary outcome was defined as the composite of death, myocardial infarction, and target vessel revascularization. ResultsDuring a median follow-up of 3.3years, in both groups, the primary outcome occurred in 12.2% of patients. After multivariable adjustment, no significant difference was observed between the two groups in the risk of primary outcome [hazard ratio (HR) 1.03, 95% confidence interval (CI) 0.59–1.79, P=0.930 for ZES compared with EES]. Similarly, there were no significant differences in the risk of death (adjusted HR 0.96, 95% CI 0.43–2.15, P=925), death or myocardial infarction (adjusted HR 0.93, 95% CI 0.46–1.88, P=0.829), and target vessel failure (adjusted HR 0.96, 95% CI 0.51–1.82, P=0.902). The incidence of definite/probable stent thrombosis was relatively low [0% (ZES) vs. 1.0% (EES), P=0.19]. ConclusionNo significant differences were observed between EES and ZES in terms of clinical outcomes for coronary CTOs at 3.3years.

Bioresorbable Vascular Scaffolds for the Treatment of Chronic Total Occlusions: An International Multicenter Registry.

There are only limited studies reporting clinical outcomes after bioresorbable vascular scaffold (BVS; Absorb; Abbott Vascular, Santa Clara, CA) implantation for coronary chronic total occlusions (CTO). The aim of this study was to evaluate the real-world feasibility and safety of BVS implantation for the treatment of CTO. We retrospectively evaluated CTO cases treated with BVS from a multicenter registry. The primary end point was target lesion failure defined as a composite of cardiac death, target vessel myocardial infarction, and clinically driven target lesion revascularization. From September 2012 to November 2015, 65 patients with CTO were successfully treated with BVS. The mean age of patients was 60.8±11.0 years; 89.2% were male and 40.0% diabetic. The mean ejection fraction was 57.7±10.8%. The mean reference vessel diameter and CTO lesion length were 3.0±0.4 and 20.2±3.0 mm, respectively. The mean number of BVS deployed per patient was 1.8±0.7, of which mean diameter and total length were 3.0±0.4 and 47.6±19.9 mm, respectively. Postdilatation with noncompliant balloons (mean diameter 3.3±0.3 mm) was performed at high pressures (18.6±5.3 atm) in all cases. Intravascular ultrasound (n=34) or optical coherence tomography (n=31) was performed in all cases. During the follow-up period (median: 453 days, 25th and 75th percentiles: 230 and 703), there were no occurrences of target lesion failure or scaffold thrombosis. BVS implantation for the treatment of CTO seems feasible and safe. Appropriate lesion preparation, high-pressure postdilatation, and the use of intravascular imaging are recommended to obtain the best possible final result.

Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI: The EXPLORE Trial

BackgroundIn 10% to 15% of patients with ST-segment elevation myocardial infarction (STEMI), concurrent coronary chronic total occlusion (CTO) in a non–infarct-related artery is present and is associated with increased morbidity and mortality. ObjectivesThe EXPLORE (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Elevation Myocardial Infarction) trial evaluated whether patients with STEMI and concurrent CTO in a non–infarct-related artery benefit from additional percutaneous coronary intervention (PCI) of CTO shortly after primary PCI. MethodsFrom November 2007 through April 2015, we enrolled 304 patients with acute STEMI who underwent primary PCI and had concurrent CTO in 14 centers in Europe and Canada. A total of 150 patients were randomly assigned to early PCI of the CTO (CTO PCI), and 154 patients were assigned to conservative treatment without PCI of the CTO (no CTO PCI). Primary outcomes were left ventricular ejection fraction (LVEF) and left ventricular end diastolic volume (LVEDV) on cardiac magnetic resonance imaging after 4 months. ResultsThe investigator-reported procedural success rate in the CTO PCI arm of the trial was 77%, and the adjudicated success rate was 73%. At 4 months, mean LVEF did not differ between the 2 groups (44.1 ± 12.2% vs. 44.8 ± 11.9%, respectively; p = 0.60). Mean LVEDV at 4 months was 215.6 ± 62.5 ml in the CTO PCI arm versus 212.8 ± 60.3 ml in the no–CTO PCI arm (p = 0.70). Subgroup analysis revealed that patients with CTO located in the left anterior descending coronary artery who were randomized to the CTO PCI strategy had significantly higher LVEF compared with patients randomized to the no–CTO PCI strategy (47.2 ± 12.3% vs. 40.4 ± 11.9%; p = 0.02). There were no differences in terms of 4-month major adverse coronary events (5.4% vs. 2.6%; p = 0.25). ConclusionsAdditional CTO PCI within 1 week after primary PCI for STEMI was feasible and safe. In patients with STEMI and concurrent CTO, we did not find an overall benefit for CTO PCI in terms of LVEF or LVEDV. The finding that early CTO PCI in the left anterior descending coronary artery subgroup was beneficial warrants further investigation. (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Segment Elevation Myocardial Infarction; NTR1108)

First-Generation Versus Second-Generation Drug-Eluting Stents in Coronary Chronic Total Occlusions: Two-Year Results of a Multicenter Registry.

BackgroundLimited data are available regarding the long-term clinical outcomes of second-generation drug-eluting stents (DES) versus first-generation DES in patients with coronary chronic total occlusion (CTO) who undergo percutaneous coronary intervention (PCI). The aim of this study was to compare the clinical outcomes of second-generation DES with those of first-generation DES for the treatment of CTO.Methods and ResultsBetween March 2003 and February 2012, 1,006 consecutive patients with CTO who underwent successful PCI using either first-generation DES (n = 557) or second-generation DES (n = 449) were enrolled in a multicenter, observational registry. Propensity-score matching was also performed. The primary outcome was cardiac death over a 2-year follow-up period. No significant differences were observed between the two groups regarding the incidence of cardiac death (first-generation DES versus second-generation DES; 2.5% vs 2.0%; hazard ratio [HR]: 0.86; 95% confidence interval [CI]: 0.37 to 1.98; p = 0.72) or major adverse cardiac events (MACE, 11.8% vs 11.4%; HR: 1.00; 95% CI: 0.67 to 1.50; p = 0.99). After propensity score matching, the incidences of cardiac death (HR: 0.86; 95% CI: 0.35 to 2.06; p = 0.86) and MACE (HR: 0.93; 95% CI: 0.63 to 1.37; p = 0.71) were still similar in both groups. Furthermore, no significant differences were observed between sirolimus-eluting, paclitaxel-eluting, zotarolimus-eluting, and everolimus-eluting stents regarding the incidence of cardiac death or MACE.ConclusionThis study shows that the efficacy of second-generation DES is comparable to that of first-generation DES for treatment of CTO over 2 years of follow-up.

Outcomes With the Use of the Retrograde Approach for Coronary Chronic Total Occlusion Interventions in a Contemporary Multicenter US Registry.

We sought to examine the efficacy and safety of chronic total occlusion percutaneous coronary intervention using the retrograde approach. We compared the outcomes of the retrograde versus antegrade-only approach to chronic total occlusion percutaneous coronary intervention among 1301 procedures performed at 11 experienced US centers between 2012 and 2015. The mean age was 65.5±10 years, and 84% of the patients were men with a high prevalence of diabetes mellitus (45%) and previous coronary artery bypass graft surgery (34%). Overall technical and procedural success rates were 90% and 89%, respectively, and in-hospital major adverse cardiovascular events occurred in 31 patients (2.4%). The retrograde approach was used in 539 cases (41%), either as the initial strategy (46%) or after a failed antegrade attempt (54%). When compared with antegrade-only cases, retrograde cases were significantly more complex, both clinically (previous coronary artery bypass graft surgery prevalence, 48% versus 24%; P<0.001) and angiographically (mean Japan-chronic total occlusion score, 3.1±1.0 versus 2.1±1.2; P<0.001) and had lower technical success (85% versus 94%; P<0.001) and higher major adverse cardiovascular events (4.3% versus 1.1%; P<0.001) rates. On multivariable analysis, the presence of suitable collaterals, no smoking, no previous coronary artery bypass graft surgery, and left anterior descending artery target vessel were independently associated with technical success using the retrograde approach. The retrograde approach is commonly used in contemporary chronic total occlusion percutaneous coronary intervention, especially among more challenging lesions and patients. Although associated with lower success and higher major adverse cardiovascular event rates in comparison to antegrade-only crossing, retrograde percutaneous coronary intervention remains critical for achieving overall high success rates.

“Putting it all together”: Highlighting the global approach to chronic total occlusion revascularization

Preprocedural planning and advanced imaging is vital to achieve a consistent and high level of success for complex coronary chronic total occlusion (CTO) revascularization. Various practice patterns exist around the world when performing coronary artery CTO revascularization. This case report highlights a fusion of global practices in CTO intervention and integration of advanced imaging to achieve successful revascularization.

TCTAP A-150 Comparison of Second- and First-Generation Drug Eluting Stent for Percutaneous Coronary Chronic Total Occlusion Intervention

TCTAP A-150 Comparison of Second- and First-Generation Drug Eluting Stent for Percutaneous Coronary Chronic Total Occlusion Intervention

Comparison of second- and first-generation drug eluting stent for percutaneous coronary chronic total occlusion intervention

BackgroundThe performance of contemporary second-generation drug-eluting stents (DESs) for percutaneous chronic total occlusion (CTO) intervention is not well established. The present study compared the efficacy and safety outcomes of second-generation DESs with those of first-generation DESs in CTO-percutaneous coronary intervention (PCI). MethodsThis retrospective analysis included 1049 consecutive CTO patients who underwent successful DES implantation (first-generation; 487 vs. second-generation; 562 patients) between March 2003 and August 2014. The primary endpoint was the composite of all-cause death, Q-wave myocardial infarction (MI), or target-vessel revascularization (TVR). ResultsDuring a follow-up of 3years, the primary endpoint incidence was 10.1% for second- and 7.7% for first-generation DES (p=0.30). After multivariable adjustment, there was no significant difference between these groups in terms of the risk of composite of death, Q-wave MI, or TVR (Hazard ratio [HR] 1.42, 95% confidence interval [CI] 0.88–2.28, p=0.15) nor in the individual risks of death (adjusted HR 1.33, 95% CI 0.69–2.56, p=0.39), Q-wave MI (adjusted HR 1.15, 95% CI 0.30–4.47, p=0.84) and TVR (adjusted HR 1.06, 95% CI 0.52–2.15, p=0.87). The incidence of definite/probable stent thrombosis was relatively low (0.5% vs.0.9%, p=0.17) throughout the follow-up period. ConclusionThe 3-year clinical outcomes of patients treated with second-generation DESs are comparable to those treated with first-generation DESs for CTO–PCI.

Rationale and indications for coronary chronic total occlusion interventions

AbstractChronic total occlusions (CTOs) are commonly found in patients with coronary artery disease and are considered the “final frontier” of coronary intervention. Despite growing interest in percutaneous coronary intervention (PCI) of CTOs along with advances in techniques and equipment, attempt rates remain low. This is most likely due to the fact that CTO PCI remains technically challenging and requires higher resource utilization. Furthermore, there remains controversy regarding the actual clinical benefit of successful CTO PCI. However, there have been a growing number of studies reporting short‐ and long‐term outcomes of CTO revascularization. We therefore sought to review the evidence and potential clinical benefits of successful CTO PCI.Answer questions and earn CME: https://www.wileyhealthlearning.com/Activity2/3691380/Activity.aspx

The retrograde approach to coronary chronic total occlusion interventions

AbstractThe results of percutaneous coronary interventions (PCI) dramatically improved in the last decades. Despite this improvement chronic total coronary occlusions (CTO) still remain a major challenge of interventional cardiology due to the complexity of these lesions. Retrograde recanalization proved to be one of the most significant amendments of the technique. Careful assessment of the occluded vessel, the donor artery and the interventional collaterals has fundamental importance for a safe and efficient procedure. High‐quality diagnostic angiogram and other imaging methods also have paramount importance for the success. The proper selection of the vascular access for retrograde CTO PCI can be challenging in patients with peripheral artery disease because of special requirements toward the guiding catheters. The latest publications demonstrated continuous improvement in the results together with decreasing complication rates of retrograde procedures. This technique significantly increased the number of patients who can be treated with PCI even with failed previous antegrade attempt.Answer questions and earn CME: https://www.wileyhealthlearning.com/Activity2/3700518/Activity.aspx

TCT-586 Comparison of second-generation with first-generation drug eluting stent for coronary chronic total occlusion intervention

TCT-586 Comparison of second-generation with first-generation drug eluting stent for coronary chronic total occlusion intervention

Retrograde approach to successfully treat antegrade failure due to subintimal hematoma of a right coronary artery chronic total occlusion

Use of antegrade dissection re-entry techniques for crossing coronary chronic total occlusions may occasionally fail due to subintimal hematoma formation. We describe use of the retrograde approach to successfully complete a right coronary artery chronic total occlusion intervention, in which re-entry was not possible after subintimal guidewire crossing due to extensive subintimal hematoma formation that compressed the distal true lumen.

Are We Ready for a New Paradigm Shift in Percutaneous Revascularization of Chronically Occluded Vessels With Well-Developed Collaterals?

Coronary chronic total occlusion (CTO) is found in up to 20% of the patients undergoing coronary angiography and represents one of the remaining challenges for interventional cardiologists [(1)][1]. Failure of attempted percutaneous coronary intervention (PCI) of CTO is high, up to 35%; more than 40