Polymorphism of p53 gene codon 72 in Kuwaiti with coronary artery disease and diabetes

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has a lower success rate than PCI of non-occluded coronary stenosis. Failure to cross the occlusive lesion with a guide wire is the main cause of unsuccessful PCI of a CTO. Multi-imaging modalities may provide valuable information for PCI of CTO. This paper reviews the role of invasive and non-invasive imaging modalities such as intravascular ultrasound, optical coherent reflectometry, CT coronary angiography and cardiac magnetic resonance imaging in facilitating percutaneous coronary intervention of CTO.     

The challenges of chronic total coronary occlusions: an old problem in a new perspective

In spite of the remarkable technological innovation and improved outcomes with percutaneous coronary revascularization, chronic coronary artery total occlusions remain a familiar source of procedural frustration and clinical uncertainty. However, considering the recent development of catheter-based technologies specific for chronic total occlusion (CTO) recanalization and the potential for drug-eluting stents to reduce restenosis and reocclusion, this challenging lesion subset is now recognized as the last formidable barrier to percutaneous revascularization success. Further, consistent observations from more recent clinical trials support successful CTO revascularization to avoid subsequent adverse cardiac events and improve long-term overall survival. This review of total coronary occlusions provides an overview of CTO pathophysiology, describes the procedural and clinical outcomes associated with CTO revascularization, and presents future directions for clinical investigation.     

Successful coronary intervention for chronic total occlusion using a retrograde approach with biradial arteries

A retrograde approach is one of the new techniques of percutaneous coronary intervention (PCI) for the treatment of chronic total occlusions (CTO). We present 4 cases of successful PCI for CTO via a retrograde approach using both radial arteries. There were no complications in these cases. We found that, selected cases, a retrograde approach using the biradial arteries in the treatment of CTO appears to be feasible.     

Retrograde approach to recanalising coronary chronic total occlusions immediately following a failed conventional attempt

Chronic total occlusions (CTO) continue to be associated with worse procedural outcomes following percutaneous coronary intervention (PCI) compared with non-occlusive lesions. A number of advances in materials and novel techniques have helped improve procedural success and have stimulated renewed interest in CTO PCI. We present 2 cases in which a conventional antegrade attempt was unsuccessful and resulted in considerable dissection distal to the occlusion. In both patients we employed a retrograde approach using septal collaterals to cross the occlusions retrogradely. This approach proved successful and can be applicable in patients with suitable collateral channels following unsuccessful conventional procedures, even in the same session.     

The management of chronic total coronary occlusions

Although recent consensus has clearly defined chronic total occlusions (CTO), attempted percutaneous coronary intervention (PCI) remains low. Histopathologically, CTOs are characterized by fibrous caps, varying degrees of plaques, and neovascularization, with both increasing with the age of the CTO. Multiple registries and studies show that successful PCI of CTOs can improve symptoms, left ventricular function, and mortality. There is overwhelming evidence that very low restenosis and reocclusion rates can be obtained with drug eluting stents after recanalization of CTOs. PCI should be considered the preferred initial revascularization modality in patients in whom a high procedural success rate may be anticipated. Novel techniques have greatly enhanced procedural success, and include 'parallel' and 'seesaw' wire techniques, balloon anchoring, subintimal tracking and reentry (STAR), retrograde approach, contralateral injection, and intravascular ultrasound (IVUS) guidance. Improvements in wire technology have largely been responsible for improved procedural success in PCI of CTO, while application of new technologies hold promise to significantly better outcomes. Magnetic resonance imaging (MRI) and multislice computed tomography (CT) are already employed in formulating treatment strategies and their role in the treatment of CTOs is likely to increase.     

Revascularization of Chronic Total Occlusions : Time to Reconsider?

Up to 20% of all coronary angiograms reveal coronary chronic total occlusions (CTOs). The lack of robust type A evidence with hard clinical outcomes on the benefits of CTO revascularization has hampered attempts to develop recommendations regarding the optimal management of CTOs. This review presents issues surrounding CTO revascularization within the framework of the appropriate use criteria ratings. Appropriate use criteria ratings downgrade CTO percutaneous coronary intervention revascularization relative to non-CTOs and to surgical revascularization. Specific aspects of CTO revascularization include ischemic burden, impact of revascularization on quality of life, risks in CTO revascularization, and the importance of complete revascularization. Contemporary data suggest CTO revascularization may have substantial impact on patient outcomes; thus, revascularization should likely be held to similar criteria as nonocclusive lesions. However, additional large clinical trial data are required to more definitively determine CTO revascularization guidelines.     

Percutaneous Coronary Intervention of Chronic Total Occlusions: When and How to Treat

Chronic coronary total occlusions (CTO) are diagnosed in up to 20% of patients with coronary artery disease and have a detrimental effect on patients' quality of life and long-term prognosis. The exponential developments in CTO percutaneous coronary intervention (PCI) equipment, recanalization techniques, and operator expertise have been merged into the hybrid approach that represents a percutaneous revascularization algorithm for treating CTOs and has led to technical success over 90% at experienced centers. Therefore, patient selection for CTO PCI should be focused on anticipated patient benefit in terms of health status and long-term prognosis rather than coronary anatomic complexity.Table of contentsThis review will provide an overview of the clinical presentation and characteristics of patients with a CTO and will discuss the essential needs toward judicious patient selection for percutaneous CTO revascularization according to contemporary knowledge. Furthermore, the current high standard revascularization techniques in dedicated CTO PCI will be discussed.     

Adjunctive Strategies in the Management of Resistant, ‘Undilatable’ Coronary Lesions After Successfully Crossing a CTO with a Guidewire

Successful revascularisation of chronic total occlusions (CTOs) remains one of the greatest challenges in the era of contemporary percutaneous coronary intervention (PCI). Such lesions are encountered with increasing frequency in current clinical practice. A predictable increase in the future burden of CTO management can be anticipated given the ageing population, increased rates of renal failure, graft failure and diabetes mellitus. Given recent advances and developments in CTO PCI management, successful recanalisation can be anticipated in the majority of procedures undertaken at high-volume centres when performed by expert operators. Despite advances in device technology, the management of resistant, calcific lesions remains one of the greatest challenges in successful CTO intervention. Established techniques to modify calcific lesions include the use of high-pressure non-compliant balloon dilation, cutting-balloons, anchor balloons and high speed rotational atherectomy (HSRA). Novel approaches have proven to be safe and technically feasible where standard approaches have failed. A step-wise progression of strategies is demonstrated, from well-recognised techniques to techniques that should only be considered when standard manoeuvres have proven unsuccessful. These methods will be described in the setting of clinical examples and include use of very high-pressure non-compliant balloon dilation, intentional balloon rupture with vessel dissection or balloon assisted micro-dissection (BAM), excimer coronary laser atherectomy (ECLA) and use of HSRA in various ‘offlabel’ settings.     

冠状动脉慢性完全闭塞病变治疗研究进展

冠状动脉慢性完全闭塞(CTO)病变是临床中较为常见的严重冠状动脉病变。这些患者通常年龄更大,合并疾病更多。CTO病变的经皮冠脉介入术治疗难度较大,成功率相对低,且并发症的发生更多,但在经验丰富中心CTO病变经皮冠脉介入术的成功率已经达到80%~90%。CTO病变血运重建的获益目前还存在争议。观察性研究和注册研究显示,开通CTO病变可以缓解心绞痛症状,改善心功能,提高运动耐量,甚至可以减少心血管事件的发生,但是尚缺乏随机对照研究的支持。     

Re-canalization of peripheral chronic total occlusions using the BridgePoint Stingray re-entry device

Percutaneous intervention of peripheral chronic total occlusions (CTO) is increasingly common, but Interventionalists still face significant barriers to successful treatment of CTO lesions in the coronary and peripheral anatomy. The greatest overall challenges are in crossing the CTO lesion and re-entering the true lumen from a successful subintimal crossing. We present a case report of a patient with a CTO of a lower extremity artery, in which treatment with a new, novel system was used to address both of these challenges.     

Real world perspective of coronary chronic total occlusion in third world countries: A tertiary care centre study from northern India

ObjectivesThe aim of this study is to determine the prevalence, clinical characteristics, angiographic profile and predictors of outcome for percutaneous coronary interventions (PCI) of coronary chronic total occlusions (CTO) in a tertiary referral centre of north India.BackgroundThere is no data on the prevalence and very few reports on clinical characteristics, angiographic profile and outcome of PCI in CTO from India.MethodsRetrospective analysis was done for the data of 12,020 patients undergoing coronary angiography (CAG) between January 2018 to January 2019 at our centre. Detailed baseline clinical, angiographic and revascularization data was collected. Outcome of CTO PCI was also noted. All baseline parameters were analysed for predicting the outcome of CTO PCI.ResultsCTO was identified in 16.3% (1968) patients undergoing CAG and in 24.4% of patients with hemodynamically significant CAD. CTO was predominantly found in LAD (48%) followed by RCA (42.9%) and LCx (25.3%) arterial distribution. Mean JCTO score was 1.93 ± 0.7. PCI as a management strategy was adopted in 456 of 1968 patients (23.1%) and was successful in 340 of 456 (74.6%) of patients. Almost all CTO PCI were attempted by an antegrade approach only. Increasing age, male sex, CTO in LCx arterial distribution and higher J CTO score were associated with poorer outcome in CTO PCI.ConclusionsCTO’s are commonly encountered during CAG procedures. In patients undergoing CTO PCI, a fair success rate can be achieved in a high volume experienced centre.     

Retrograde balloon hemostasis

Despite improvements in current devices and techniques for complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI), procedural complications, including coronary perforation, still occur and could be life-threatening. A patient with a history of multivessel coronary artery disease and a CTO of the right coronary artery (RCA) underwent successful retrograde crossing of an RCA CTO. After wiring the CTO body and lesion dilatation, a drug-eluting stent was implanted in the distal RCA toward the posterior descending artery. A large Ellis type III perforation occurred at the distal edge of the stent. Septal crossing with a balloon and tamponade of the perforation site through the retrograde collaterals followed, as the RCA was not suitable to accommodate easily both the covered stent and the balloon simultaneously. This case report presents a novel approach the “septal retrograde ping-pong” technique, which demonstrates successful treatment of coronary perforations by utilizing a retrograde approach through a septal collateral. This technique proves to be effective in situations where the conventional antegrade balloon or covered stent delivery methods are not feasible or unsuccessful. This innovative approach offers a promising alternative for managing challenging cases of coronary perforations, providing new insights and potential solutions for interventional cardiologists.     

Update on Percutaneous Management of Chronic Total Occlusion

Management of chronic total occlusions (CTOs) remains a challenge for interventional cardiologists. Despite advances in the design of angioplasty hardware and increased operator experience, percutaneous angioplasty of CTO still is associated with a relatively low primary success rate compared with non-CTO. Although the stent has dramatically improved initial and long-term outcome, the incidence of restenosis and reocclusion continues to be high in patients with excessive lesion length and/or small vessel size. Adjunctive pharmacotherapy, such as platelet glycoprotein IIb/IIIa receptor antagonist, may play an important role in the prevention of early reocclusion as well as late restenosis. Similarly, radiation therapy may be useful in the prevention/treatment of in-stent restenosis. Although observational data have shown a poor long-term survival in patients with CTO, convincing prospective or randomized data are lacking. Future investigations will need to focus on the long-term outcome of patients with CTO referred for angioplasty compared with CABG or medical therapy.     

Chronic total occlusion percutaneous coronary intervention case selection and techniques for the antegrade‐only operator

Coronary chronic total occlusions (CTO) remain a difficult lesion subset to treat. Although CTOs are present at coronary angiography in 15–20% of patients, only a small fraction of eligible patients will be offered percutaneous treatment. Recent publications from centers with dedicated CTO programs using the full range of antegrade and retrograde techniques suggest success rates in the range of 90% even when little anatomic exclusion are used. However, many patients with clinically appropriate CTO targets have simpler anatomy that can predictably be managed without the selected skills and equipment. The purpose of this review is to provide skilled percutaneous coronary intervention operators who have not specialized in complex retrograde CTO techniques, an algorithm for the selection and antegrade management of appropriate CTO cases. Core equipment and techniques are discussed. © 2014 Wiley Periodicals, Inc.     

Blunt microdissection and rotational atherectomy: an effective combination for the resistant chronic total occlusion

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has a lower success rate than nontotal occlusions. Like nontotal coronary occlusions, successful procedural outcomes of CTOs confers improvement in clinical outcomes. Reasons for unsuccessful PCI of CTOs may stem from various steps of the procedure including failure to cross the occlusion with a guidewire or a balloon, or failure to adequately dilate or modify the lesion. The Frontrunner blunt microdissection device is designed to improve the odds of guidewire passage through coronary occlusions, whereas the Rotablator rotational atherectomy device is intended for plaque modification, especially in resistant, elastic or calcific lesions. The Frontrunner and Rotablator can each facilitate the procedure at their respective junctures; the combined use of these technologies can enhance the overall PCI success rates, especially regarding difficult CTOs. This case presentation encounters two technical challenges: the inability of the balloon catheter to cross the CTO, and the inability to recross the occlusion with the less favorable RotaWire. In this case, the combined use of the Frontrunner and Rotablator devices was necessary to achieve overall procedural success. When tackling difficult CTOs, a comprehensive strategy that encompasses multiple devices and technologies can enable ultimate procedural success.     

慢性完全闭塞病变行经皮冠状动脉介入治疗对供血动脉定量血流分数的影响

目的探讨冠状动脉慢性完全闭塞(CTO)病变成功行经皮冠状动脉介入治疗(PCI)对其供血动脉定量血流分数(QFR)的影响。方法入选上海交通大学医学院附属瑞金医院2017年7月至2021年1月成功行PCI的单支CTO病变且供血血管符合QFR计算标准的患者30例。分别于CTO病变血管开通前后应用不同的血流模型,即固定血流模型和对比剂血流模型,对供血血管进行QFR评估,观察CTO-PCI前后QFR值的变化,并收集患者的临床基线资料,分析其影响QFR值变化的因素。结果CTO-PCI术后供血血管对比剂血流QFR值显著高于术前[(0.74±0.17)比(0.69±0.19),P<0.001],且冠状动脉侧支循环Rentrop分级是预测QFR变化值的独立预测因素(β=0.36,P=0.043)。结论CTO-PCI术后供血血管QFR值是显著升高的,且与Rentrop侧支循环分级相关。     

Impact of treatment strategies on long-term outcome of CTO patients

BackgroundThe percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains debated. Therefore the aim of this large-scale observational multi-center registry was to compare the long-term outcome of CTO patients undergoing different therapeutic approaches comparing successful CTO revascularization either by PCI or coronary artery bypass graft (CABG), failed CTO-PCI and optimal medical therapy (OMT) alone.Methods and resultsA total of 6630 CTO patients were enrolled from two high-volume centers to compare different treatment strategies. All procedures were performed by high-volume CTO operators in tertiary university hospital. Successful CTO-PCI was performed in 3906 patients, failed CTO-PCI in 1479 patients, 412 patients underwent CABG surgery and 833 patients were treated with OMT. During the 5-year follow-up period, 1019 (15%) patients died. Kaplan-Meier analysis unveiled a significantly improved long-term outcome for CTO patients undergoing revascularization either by PCI or by CABG compared to patients with failed CTO-PCI or OMT alone (log-rank P < 0.001). In the multivariate Cox-regression analysis successful CTO-PCI was associated with significantly improved long-term outcome compared to patients under OMT (adj. HR 0.39, 95%CI 0.33–0.45, P < 0.001) or CABG (adj. HR 0.68, 95%CI 0.53–0.86, P = 0.002) independent of clinical confounders encompassing age, BMI, diabetes, kidney function and left ventricular function.ConclusionsThis study showed an improved long-term outcome for CTO revascularization compared to optimal medical therapy, independent from revascularization mode, with the highest survival rate in patients undergoing successful CTO-PCI.     

Expressman导引延伸导管辅助主动迎接技术成功治疗冠状动脉慢性完全闭塞病变一例报道

逆向介入途径是治疗冠状动脉慢性完全闭塞病变(CTO)的主要技术之一,而逆向导丝体外化是CTO患者经皮冠状动脉介入治疗(PCI)成功的关键。随着延伸导管等新器械的出现及主动迎接技术(AGT)等新技术的不断发展,复杂CTO治疗成功率逐渐升高。本文报道了1例Expressman导引延伸导管辅助AGT成功治疗的冠状动脉CTO患者,以为该技术的临床应用提供参考。     

A new percutaneous porcine coronary model of chronic total occlusion

OBJECTIVE: Chronic total occlusion (CTO) of coronary arteries represents a challenge for percutaneous treatment. Although ameroid constrictors have been used to create CTOs from extrinsic compression of coronary arteries, this model is not suitable for evaluation of novel angioplasty equipment. Thus, the objective of this study was to create a new percutaneous animal model of CTO. METHODS: To create an animal model of CTO, we implanted copper-plated stents in the left circumflex coronary arteries of 18 pigs, and assigned the pigs to early group (n = 6; sacrifice at approximately 1 week), intermediate group (n = 6; sacrifice at approximately 4 weeks), and late group (n = 6; sacrifice at approximately 8 weeks). RESULTS: Follow-up angiography prior to sacrifice revealed complete occlusion in 14 of 17 animals, with the subtotal occlusive lesions (mean 60% stenosis) only in the early group. Most of the pigs with total occlusions (12 of 14) showed bridging collateral flow greater than or equal to grade 2 (grade 2: 4; grade 3: 8). Histology revealed organizing thrombus in the early group with persistent inflammation, and organized thrombus with fibrosis and calcification in the intermediate and late groups. Interestingly, there were fibrotic components in the proximal and distal edges of the occlusions with softer, organizing thrombus in the middle of the CTO in the late group, suggesting that the major areas of difficulty are at the entrance and exit segments of the CTO with percutaneous recanalization. CONCLUSION: This study shows the feasibility and reproducibility of a new porcine coronary percutaneous CTO model. This model may be useful in improving our percutaneous treatment of CTO.     

Primary stenting of occluded native coronary arteries II--rationale and design of the PRISON II study: a randomized comparison of bare metal stent implantation with sirolimus-eluting stent implantation for the treatment of chronic total coronary occlusions

Primary intracoronary stent placement after successfully crossing chronic total occlusions (CTO) decreases the high restenosis rate at long-term follow-up compared with conventional balloon angioplasty. Several studies have shown the efficacy of sirolimus-eluting stents in selected groups of patients. Whether sirolimus-eluting stents are superior to bare metal stents in CTO is unknown. In this prospective randomized trial, bare metal stent implantation will be compared with sirolimus-eluting stent implantation for the treatment of CTO. A total of 200 patients will be followed up for 12 months with angiographic follow-up at 6 months. Quantitative coronary analysis will be performed by an independent core laboratory. The primary end point is the binary angiographic restenosis and reocclusion rate.