Recanalization Of Chronic Total Occlusion Research Articles

Long-term MACCE Rate after Retrograde Compared to Antegrade Recanalization of Chronic Total Coronary Occlusions

Background: The recanalization success rate of chronic total occlusion (CTO) percutaneous coronary interventions (PCI) can be increased by the retrograde approach. However, the long-term outcome of patients undergoing retrograde procedures is unknown. Aim: We aimed to evaluate the long-term MACCE (major adverse cardiac and cerebrovascular event) rate (death, myocardial infarction, coronary artery bypass surgery and stroke) in patients after retrograde versus antegrade CTO-PCI. Methods and results: In a prospective single center study from January 2008 to June 2012, 396 consecutive patients with CTO´s (≥ 3 months old) were enrolled. Mean age was 63.4 ± 10.3 years, 86.4% were male. The recanalization success rate of the total patient cohort was 88.6%. The retrograde PCI, only attempted after a failed antegrade intervention, was performed in 18% (n = 71) of patients. Long-term MACCE rate (mean follow up 2.3 ± 1.6 years) was significantly higher in the unsuccessful compared to the successful CTO-PCI group (23.1% versus 9.4%, p = 0.01) and this was also the case in the subgroup of antegrade CTO-PCI. In the retrograde subgroup, however, procedural success had no impact on outcome. As a possible explanation for this surprising finding, patients with unsuccessful retrograde CTO-PCI had a significantly better collateral connection compared to patients with an unsuccessful antegrade approach. Conclusions: Long-term MACCE rate after unsuccessful recanalization was significantly higher which was driven by a higher MACCE rate after unsuccessful versus successful antegrade approach. In contrast, procedural success in the retrograde group had no impact on outcome.

Which parameters are important before attempting chronic total occlusions recanalization?

Which parameters are important before attempting chronic total occlusions recanalization?

The Long-Term Prognostic Value of Negative Contrast Stress Echocardiography

Chronic total occlusion (CTO) is probably caused by thrombus and lipid-rich cholesterol esters that are replaced over time by collagen and calcium deposition. Experimental models showed endothelial cell necrosis in response to vessel ligation, whereas more recent models suggest that the endothelium might retain viability guiding the subsequent development of CTO, including CTO neo-revascularization, which occurs within the lumen and in various layers of the vessel wall, by the release of paracrine substances. It is uncertain whether after CTO recanalization the recovery of anterograde reverses endothelial dysfunction, thus promoting vasodilation and positive remodeling.

Serial Intravascular Ultrasound Findings After Treatment of Chronic Total Occlusions Using Drug-Eluting Stents

Morphologic changes after chronic total occlusion (CTO) treatment with drug-eluting stents (DESs) have not been assessed in detail. Our aim was to use both baseline and follow-up intravascular ultrasound studies to evaluate the morphologic changes and, especially, the changes in distal vessel size and the effect of subintimal stenting after treatment of CTOs with DES. We analyzed serial follow-up intravascular ultrasound (baseline and follow-up at 9 ± 2 months) after DES implantation into 40 CTOs. Overall, 33 CTOs were treated by the anterograde approach; and 7 were treated by the retrograde approach. Minimum lumen cross-sectional area (CSA) trended toward a decrease from baseline to follow-up (4.8 ± 1.7 vs 4.5 ± 1.7 mm(2), p = 0.10), although the minimum stent CSA (4.8 ± 1.7 vs 4.9 ± 1.7 mm(2), p = 0.26) did not change. The distal reference, but not the proximal reference lumen CSA, increased significantly at follow-up (3.8 ± 2.0 to 5.1 ± 2.3 mm(2), p = 0.0004). Late-acquired stent malapposition was seen in 17 patients (42.5%). In 8 CTOs (20%), a part of the stent was implanted into a subintimal space; in these 8 patients, maximum percent neointimal hyperplasia and minimum lumen area was similar in the subintimal segment compared with the adjacent intraplaque segment. The frequency of late-acquired stent malapposition was similar. In conclusion, after CTO treatment with DES, distal vessel enlargement was detected. Subintimal stenting after recanalization of CTO was not inferior compared with stenting within the plaque in terms of long-term morphologic impact.

Abstract 17509: The Influence of Chronic Total Occlusion Recanalization on Fractional Flow Reserve Value of Collateral Donor Artery

Background: Although recent guidelines recommend the use of fractional flow reserve (FFR) measurements to make decisions for patients with multi-vessel disease and borderline lesions, the presence of a concomitant chronic total coronary occlusion (CTO) may alter the FFR of the interrogated vessel due to collateral circulation. The purpose of this study was to investigate the change in donor artery FFR associated with PCI of a concomitant CTO. Methods: Nineteen consecutive patients who underwent PCI for CTO lesions were prospectively enrolled. All patients underwent myocardial stress perfusion scintigraphy before PCI. An intracoronary pressure/temperature sensor-tipped wire was advanced through a guiding catheter to a point 7cm distal from the ostium of both non-target arteries. At steady-state hyperemia, hemodynamics including FFR and the hyperemic mean transit time (Tmn), which are inversely proportional to coronary flow velocity, were calculated before and immediately after PCI. Coronary blood flow (CBF) was calculated as 1/Tmn х π х (diameter/2) 2 . Coronary wedge pressure was also measured after 30 s of balloon occlusion within the stented segment of the target arteries after PCI. Results: The average FFR values of the donor artery before PCI were 0.89±0.09. None of patients had signs of ischemia in the territory of the donor arteries, even though five patients had an FFR value of <0.80 in the donor arteries. After the successful recanalization of the target arteries, FFR values in the donor artery increased to 0.95±0.06 (mean difference, 0.06 [0.04 to 0.09]: p <0.001). On the other hand, CBF in the donor artery significantly decreased from 35.5±15.7 to 25.7±13.8 (p=0.02). No linear correlation was identified between the change of FFR in the donor artery and coronary wedge pressure in the occluded artery (r= -0.05, p= 0.78). Conclusions: Revascularization of a CTO lesion provides moderate increase in the FFR value of the collateral donor artery as a result of the reduction of coronary blood flow. Therefore, the hemodynamic significance of intermediate stenosis in the donor artery by FFR should be carefully evaluated in the presence of CTO.

Collateral Circulation in Chronic Total Occlusions – an interventional perspective

Human coronary collaterals are inter-coronary communications that are believed to be present from birth. In the presence of chronic total occlusions, recruitment of flow via these collateral anastomoses to the arterial segment distal to occlusion provide an alternative source of blood flow to the myocardial segment at risk. This mitigates the ischemic injury. Clinical outcome of coronary occlusion ie. severity of myocardial infarction/ischemia, impairment of cardiac function and possibly survival depends not only on the acuity of the occlusion, extent of jeopardized myocardium, duration of ischemia but also to the adequacy of collateral circulation. Adequacy of collateral circulation can be assessed by various methods. These coronary collateral channels have been used successfully as a retrograde access route for percutaneous recanalization of chronic total occlusions. Factors that promote angiogenesis and further collateral remodeling ie. arteriogenesis have been identified. Promotion of collateral growth as a therapeutic target in patients with no suitable revascularization option is an exciting proposal.

COMPLICATIONS OF RECANALIZATION OF CHRONIC TOTAL OCCLUSION.

Percutaneous Coronary Intervention (PCI) of Chronic Total Occlusions (CTO) is an accepted revascularization procedure. These complex procedures carry with them certain risks and potential complications. Complications of PCI such as contrast induced renal dysfunction, radiation, etc, assume more relevance given the length and complexity of these procedures. Further, certain complications such as donor vessel injury, foreign body entrapment are unique to CTO PCI. A thorough understanding of the potential complications is important in mitigating risk during these complex procedures.

Role of CT Coronary Angiography in Recanalization of Chronic Total Occlusion

Chronic total occlusion (CTO) is considered as the most challenging frontier in interventional cardiology and the last one to be conquered. With availability of state of the art hardware, wires and catheters in particular and increased skills of the operators, the success rate for recanalization of CTO by percutaneous catheter intervention (PCI) has improved. Yet the complications rate and longterm adverse events are high, mostly due to failure in tracking or navigation of hardware through the occluded CTO segment, prolonged exposure to radiation and high doses of contrast used. Therefore, proper selection of patient is of utmost importance. One of the major challenges for successful CTO recanalization is satisfactory visualization of the occluded CTO segment. Conventional invasive catheterization fails to fill the gap and the shortcomings and handicaps of such invasive imaging can be resolved with the use of non-invasive CT coronary angiography (CTCA). CTCA helps to better define the morphological features of the occluded CTO segment, which are established predictors of success, like the actual length of the occluded segment and any calcification or tortuosity in its course. Integration of reconstructed three-dimensional CT coronary images with twodimensional fluoroscopic images, offers directional guide to select the best angiographic plane for visualization of angiographically “missing segment”. With advances in CT technology, CTCA has now become an established technology for pre-procedure evaluation of CTO segment, thereby help in planning and execution of successful PCI.

In-hospital and long-term outcomes after percutaneous coronary intervention for chronic total occlusion in elderly patients: A consecutive, prospective, single-centre study

Elderly patients are increasingly referred for complex percutaneous coronary interventions (PCI), including recanalization of chronic total occlusion (CTO). To assess the feasibility, safety and clinical benefits associated with CTO-PCI in elderly patients. Consecutive patients (n=356) who underwent CTO-PCI in our institution between January 2008 and December 2011 were prospectively included. The short-term outcomes of CTO-PCI were assessed by comparing the rates of successful recanalization and postoperative complications in patients aged ≥ 75 years and those < 75 years. The clinical effect of successful recanalization was evaluated in a 20-month follow-up analysis in patients ≥ 75 years. Although patients ≥ 75 years (n = 93) had more complex coronary artery disease, the procedural success rate was similar to that in younger patients (78.2% vs. 74.3%, respectively; P = 0.41). Postoperative complications were more frequent in older patients (5.4% vs. 0.4%; P = 0.005). Major adverse cardiac event-free survival analysis at 20 months revealed that successful revascularization was indicative of a better prognosis in older patients (hazard ratio: 0.43, 95% confidence interval: 0.19-0.96; P = 0.039). Elderly patients have more complex coronary disease and are at a higher risk of postoperative complications. Nevertheless, we observed a similar success rate for CTO-PCI in elderly patients as for younger patients. Successful CTO recanalization improved the event-free survival rate at 20 months. Thus, CTO-PCI constitutes an alternative strategy for treating selected elderly patients.

TCT-66 Long-term Clinical Outcomes of Percutaneous Coronary Intervention Using Drug-Eluting Stent for Native Coronary Chronic Total Occlusion

The benefit on prognosis after successful recanalization of chronic total occlusion (CTO) lesions is uncertain. A total of 1173 consecutive patients (mean age 60 years, 82.7% men) with CTOs of native coronary vessels in which percutaneous coronary intervention (PCI) was attempted was enrolled from

TCT-460 Septal Surfing in Retrograde Recanalization of Chronic Total Occlusions: The Quebec Experience

TCT-460 Septal Surfing in Retrograde Recanalization of Chronic Total Occlusions: The Quebec Experience

GW26-e1447 Recanalization of coronary chronic total occlusion and its effects on myocardial perfusion and long term outcome

GW26-e1447 Recanalization of coronary chronic total occlusion and its effects on myocardial perfusion and long term outcome

TCT-563 Results after recanalization of true coronary chronic total occlusions with the sirolimus eluting abluminal coated stent compared with the zotarolimus eluting stent

TCT-563 Results after recanalization of true coronary chronic total occlusions with the sirolimus eluting abluminal coated stent compared with the zotarolimus eluting stent

TCT-585 Drug Eluting Stent With Bioresorbable Polymer For Chronic Total Occlusion: 1 Year Outcomes From e-NOBORI Registry

Chronic total occlusion (CTO) recanalization is still a very challenging topic in the field of coronary intervention. Data on the performance of drug eluting stent (DES) with bioresorbable polymer in CTO are limited. The aim of our study is to assess 1-year clinical outcomes in CTO lesion management

TCT-161 Development of a new prediction rule for chronic total occlusion recanalization failure: The Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) score

The J-CTO (Multicenter Chronic Total Occlusion [CTO] Registry in Japan) score was developed to predict the probability of successful guidewire crossing within 30 minutes. However, guidewire crossing alone does not ensure final success of CTO PCI. We therefore sought to develop a novel parsimonious

GW26-e1460 The Experience of Coronary Chronic Total Occlusions Recanalization used A “Crowbar Effect” new skill

GW26-e1460 The Experience of Coronary Chronic Total Occlusions Recanalization used A “Crowbar Effect” new skill

Modified contrast microinjection technique to facilitate chronic total occlusion recanalization.

To assess the efficacy and safety of the modified contrast microinjection technique to facilitate chronic total occlusion recanalization. The success rate of chronic total occlusion percutaneous coronary intervention (CTO-PCI) does not exceed 90% even in the most experienced centres. We have previously demonstrated that a large volume of contrast injected into the subintimal space can facilitate recanalization but is limited by a risk of serious complication. The aim of this study was to assess the application, efficacy and safety of a modified contrast microinjection technique that utilizes the injection of a much smaller volume of contrast in CTO-PCI. A retrospective analysis of patients in whom the modified microinjection technique was utilised in patients undergoing CTO-PCI at five tertiary centres was conducted. Of 1,192 patients who underwent CTO-PCI, the microinjection technique was used in 59 patients (4.7%). The majority of CTOs treated were in the right coronary artery (79.7%), were of high complexity and 35.6% of lesions had a least one previously failed PCI attempt. The modified microinjection technique was used for more than one indication in 7 (11.9%) of patients. The success rate was 81.4%. There were no procedural complications related to the use of the reported modified microinjection. Initial experience with the modified microinjection demonstrates that it can be performed safely, is reproducible, and is broadly applicable. Whilst not required for all CTO procedures it can be a helpful adjunctive tool to increase the likelihood of success especially in complex, or refractory cases, without compromising the safety of the procedure. © 2015 Wiley Periodicals, Inc.

Predictors of restenosis following contemporary subintimal tracking and reentry technique: The importance of final TIMI flow grade.

To identify predictors of restenosis after recanalization of chronic total occlusions (CTOs) with the Subintimal Tracking And Reentry (STAR) technique. STAR is associated with high rates of restenosis but the associated factors are not clear. Understanding the underlying mechanisms may be important to improve STAR outcomes and possibly other contemporary CTO recanalization techniques utilizing extensive subintimal dissection and stenting. We retrospectively analyzed 211 lesions that underwent a STAR procedure (between 2002 and 2013) with a final Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3. One-hundred and nineteen lesions that received drug eluting stents (DES) and underwent follow-up angiography were included in the final analysis. Of the 119 lesions treated with DES following STAR, 75 restenoses were observed (63.0%). Utilizing multivariate analysis, TIMI flow grade in the recanalized artery following stent implantation at the end of the index procedure was the only independent predictor of restenosis. Following recanalization of a CTO with STAR, final TIMI flow predicted future restenosis or reocclusion. As a bailout technique, STAR resulted in a high acute success rate with good safety and acceptable long-term results. When poor flow is observed following recanalization, and prior to stent implantation, a two-step strategy whereby a second procedure is performed at an interval to maximize coronary flow at the end of the procedure may be considered with the goal to reduce the risk of future restenosis or total vessel occlusion following STAR.

Outcomes of Native Superficial Femoral Artery Chronic Total Occlusion Recanalization After Failed Femoropopliteal Bypass: Should We Shift the Redo Paradigm?

Outcomes of Native Superficial Femoral Artery Chronic Total Occlusion Recanalization After Failed Femoropopliteal Bypass: Should We Shift the Redo Paradigm?

Assessment of Local Dose Reference Values for Recanalization of Chronic Total Occlusions and Other Occlusions in a High-Volume Catheterization Center

The increasing number and complexity of these procedures have led to a higher number of patients at risk for tissue reactions like skin injuries. Monitoring of their dose indicators is essential in recognizing these patients. The aim of this work was to determine local diagnostic reference levels (DRLs) for recanalization of chronic total occlusion (CTO) and other occlusions procedures. All data from patients who underwent cardiac procedures were reviewed and classified according to their complexity. Dose indicators such as fluoroscopy time (FT), dose area product (DAP), and air kerma at patient entrance reference point (AKr) were recorded. Correlations with patient's body mass index, operators, procedure strategy, and complexity were studied. For CTO, the mean DAP, AKr, and FT were 252 ± 234 Gycm(2), 3,985 ± 3,579mGy, and 47 ± 36minutes, respectively. To better reflect the non-Gaussian distribution of data, the median and the 75th percentile values were also reported: median DAP, 172 Gycm(2); 75th percentile DAP, 350 Gycm(2); median AKr, 2,714mGy; and 75th percentile AKr, 5,921mGy. A tentative new set of values were suggested to take into account the complexity difference in recanalization of total occlusions according to their antegrade or retrograde approach. These approach-specific DRLs for total occlusions were mean DAP (120 ± 114 Gycm(2)), mean AKr (1,789 ± 1,933mGy), and mean FT (22 ± 18minutes) for antegrade approach and mean DAP (459 ± 304 Gycm(2)), mean AKr (6,881 ± 4,243mGy), and mean FT (82 ± 40minutes) for retrograde approach. The other significant values were median DAP (84 Gycm(2)), 75th percentile DAP (147 Gycm(2)), median AKr (1,160mGy), and 75th percentile AKr (2,176mGy) for antegrade approach and median DAP (422 Gycm(2)), 75th percentile DAP (552 Gycm(2)), median AKr (6,295mGy), and 75th percentile AKr (8,064mGy) for retrograde approach. In conclusion, a set of local DRL values from a large center were assessed. DRLs were provided for antegrade and retrograde approaches, reflecting the difference in difficulty from these 2 kinds of CTOs. The wide dose estimator values variations were explained through procedure complexity. The values obtained for the other more classic percutaneous coronary interventions were comparable with those found in the literature.