Recanalization of Chronic Total Coronary Occlusions Using a Laser Guide Wire: A Pilot Study

Objectives. This study sought to prospectively evaluate the performance of a laser guide wire in crossing chronic total coronary occlusions in patients with a failed previous mechanical guide wire attempt.Background. Despite continued refinement of mechanical hardware available for coronary angioplasty, restoration and maintenance of blood flow through a chronically occluded coronary artery remains a true challenge.Methods. Fifty patients with a chronic total coronary occlusion and a previous failed attempt at recanalization using mechanical guide wires were included. A mechanical attempt to cross the occlusion was repeated. In case of failure, an additional attempt was made with the laser guide wire.Results. The median age of occlusion was 22 weeks (range 5 to 200), and the occlusion length was 23 ± 11 mm (mean ± SD). A repeat mechanical attempt was successful in six cases (12%). Dissection occurred in five other cases, and device crossover was not attempted. Thus, in 39 patients an attempt was made with the laser guide wire, with successful recanalization in 23 (59%). Thereby the overall success rate increased from 12% to 58% (29 of 50 patients). The amount of contrast medium used was 515 ± 154 ml, fluoroscopy time was 99 ± 43 min, and total procedure time was 2 h 48 min (±55 min). Procedural success was achieved in 26 cases and clinical success (procedural success without in hospital events) in 24. In-hospital events were two non–Q wave myocardial infarctions related to subacute reocclusion. In one patient, a balloon dilation after laser guide wire perforation resulted in tamponade requiring pericardiocentesis. After a successful procedure, the angina class decreased from 2.9 ± 0.2 to 1.4 ± 0.7 at 3 months of clinical follow-up. Six-month angiographic follow-up was completed in all 24 eligible patients and showed vessel patency in 20 (80%).Conclusions. The use of the laser guide wire for recanalization of chronic total coronary occlusions refractory to treatment with mechanical guide wires is feasible and relatively safe and was successful in 59% of cases. This device must thus be considered a valuable addition to the interventional armamentarium and accordingly will be evaluated in a randomized clinical trial.     

Changes in Left Ventricular Function After Coronary Recanalization by Percutaneous Transluminal Coronary Angioplasty (PTCA)

Forty-six patients (21 with stable angina and 25 with chronic myocardial infarction, 37 men) with a total chronic proximal coronary occlusion and collateral vessels to the distal part of the occluded artery (30 LAD, 10 RCA and 6 CX properly distributed in both groups) were studied angiographically before and 2 to 8 months (mean 6) after balloon angioplasty. The patients were divided in six subgroups: A) Angina pectoris no matter the result of recanalization (n = 21); B) Myocardial infarction no matter the result of recanalization (n = 25); C) Angina pectoris with successful recanalization and open coronary (O.C.) > 50% at follow-up (n = 13); D) Angina pectoris with unsuccessful recanalization and/or restenosis or closed coronary (C.C.) at follow-up (n = 8); E) Myocardial infarction with successful recanalization and O.C. > 50% at follow-up (n = 8); F) Myocardial infarction with unsuccessful recanalization and/or restenosis or C.C. at follow-up (n = 17). No subgroup showed statistical differences (p > 0.05) in LVEDP before (B) and at follow-up (FU). On the other hand, several measurements were statistically different in the subgroup A at B and at FU: Ejection fraction (EF) [57.3 +/- 12.3 and 64.2 +/- 19.4%; p = 0.02]; Regional wall motion (RWM) measured in the region of the affected coronary [18.7 +/- 9.6 and 23.6 +/- 11.8%; p = 0.05]; Minimal wall motion (MWM) measured in the site of lesser parietal movement [14.3 +/- 13.1 and 25.8 +/- 26.2%; p = 0.02]. In the subgroup C the following differences were observed: EF [58.4 +/- 12.3 and 69.0 +/- 12.4%; p = 0.003]; RWM [16.3 +/- 8.4 and 25.4 +/- 8.2%; p = 0.005]; MWM [14.7 +/- 15.1 and 27.9 +/- 18.0%; p = 0.0001]. In the other considered subgroups we did not reach significant differences (p > 0.05) in these measurements. We conclude that recanalization of a chronic coronary occlusion improves left ventricular contractile function in the presence of viable myocardium and that MSF is the most sensitive among the studied variables to separate anginal patients from the patients without viable myocardium after successful recanalization.     

Randomized Comparison of a CrossBoss First Versus Standard Wire Escalation Strategy for Crossing Coronary Chronic Total Occlusions: The CrossBoss First Trial

Objectives

The authors performed a multicenter, randomized-controlled, clinical trial comparing upfront use of the CrossBoss catheter versus antegrade wire escalation for antegrade crossing of coronary chronic total occlusions.

Mortality 10 Years After Percutaneous or Surgical Revascularization in Patients With Total Coronary Artery Occlusions

BackgroundThe long-term clinical benefit after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with total occlusions (TOs) and complex coronary artery disease has not yet been clarified.ObjectivesThe objective of this analysis was to assess 10-year all-cause mortality in patients with TOs undergoing PCI or CABG.MethodsThis is a subanalysis of patients with at least 1 TO in the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which investigated 10-year all-cause mortality in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial, beyond its original 5-year follow-up. Patients with TOs were further stratified according to the status of TO recanalization or revascularization.ResultsOf 1,800 randomized patients to the PCI or CABG arm, 460 patients had at least 1 lesion of TO. In patients with TOs, the status of TO recanalization or revascularization was not associated with 10-year all-cause mortality, irrespective of the assigned treatment (PCI arm: 29.9% vs. 29.4%; adjusted hazard ratio [HR]: 0.992; 95% confidence interval [CI]: 0.474 to 2.075; p = 0.982; and CABG arm: 28.0% vs. 21.4%; adjusted HR: 0.656; 95% CI: 0.281 to 1.533; p = 0.330). When TOs existed in left main and/or left anterior descending artery, the status of TO recanalization or revascularization did not have an impact on the mortality (34.5% vs. 26.9%; adjusted HR: 0.896; 95% CI: 0.314 to 2.555; p = 0.837).ConclusionsAt 10-year follow-up, the status of TO recanalization or revascularization did not affect mortality, irrespective of the assigned treatment and location of TOs. The present study might support contemporary practice among high-volume chronic TO-PCI centers where recanalization is primarily offered to patients for the management of angina refractory to medical therapy when myocardial viability is confirmed. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972)     

慢性完全闭塞病变介入治疗技巧

约1/3接受冠状动脉造影检查的患者可发现慢性完全闭塞（CTO）病变。CTO病变行经皮冠状动脉介入治疗（PCI）的意义在于缓解患者心绞痛症状,改善心功能并减少冠状动脉搭桥的需要。熟悉和掌握CTO病变介入治疗技巧对于提高手术成功率、改善患者的远期预后至关重要。现就CTO病变PCI术的基本和高级技巧,包括器械的选择加以综述。     

Prognostic Value of Exercise Myocardial Scintigraphy in Patients with Coronary Chronic Total Occlusions

Objectives: To evaluate the prognostic value of exercise myocardial scintigraphy in patients undergoing incomplete revascularization by means of percutaneous coronary intervention (PCI) with at least a residual chronic total occlusion (CTO) left untreated. Methods: Of 569 consecutive patients with multivessel disease undergoing myocardial scintigraphy after incomplete revascularization by PCI between March 1997 and December 2004, 126 (79% male, 64±10 years) with ≥ 1 residual CTO fulfilled the eligibility criteria and entered in the study. Hard events defined as cardiac death and myocardial infarction, soft events defined as incidence of unstable angina and PCI procedures, and their composite were assessed at a median follow‐up period of 44 months. Results: Hard events were observed in six patients (4.8%). All of them had severely abnormal perfusion defects detected by myocardial scintigraphy. Soft events occurred in 0 (0%), 10 (7.9%), and 15 (11.9%) patients with normal, mildly abnormal, and severely abnormal perfusion, respectively. In the Kaplan–Meier analysis, the log‐rank test was statistically significant across patients stratified by summed stress score either in terms of hard, soft and hard, or soft events. Univariate and multivariate Cox proportional‐hazards showed an incremental significant information when the scintigraphic variables were added to clinical, angiographic, left ventricular ejection fraction, and Duke treadmill score, for prediction of the composite of hard and soft cardiac events (P < 0.006). Conclusions: Among patients with a residual CTO left untreated after PCI, myocardial perfusion imaging provides significant independent information concerning the subsequent risk of cardiac events. (J Interven Cardiol 2010;23:139‐148)     

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

Background: Several studies have illustrated the safety and the procedural outcome of high‐frequency vibrational energy in guidewire refractory chronic total occlusions (CTOs). Aim: To evaluate the advantage of high‐frequency vibrational energy device (CROSSER Catheter) use in coronary complex CTO revascularization as primary strategy. Methods: CROSSER was used as a primary approach if four or more unfavorable angiographic features were observed in the CTO lesions. Results: 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]. Conclusion: 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. (J Interven Cardiol 2010;23:130‐138)     

Simplified Method for Insertion of Steerable Guide into the Left Atrium Using a Pigtail Guide Wire During the MitraClip® Procedure: A Technical Tip

Background

To assess whether a new floppy pigtail guidewire provides sufficient support for introduction of the 22F‐steerable guide catheter (SG) into the left atrium and is less time‐consuming during the MitraClip^®‐procedure without necessity of probing and inserting a stiff wire into the pulmonary vein.

Methods

In group 1, traditional probing of the left upper pulmonary vein and insertion of a standard stiff wire was used. In group 2, direct insertion of the floppy pigtail guidewire directly after transseptal puncture was used.

Results

Patients in group 1 (n = 18) and group 2 (n = 21) did not differ significantly with respect to mitral regurgitation severity (3.2 ± 0.4 vs 3.2 ± 0.4; P = 0.814) and etiology (functional 78% vs 71%, P = 0.651). Comparing both methods, a significant reduction in time‐to‐SG was observed in group 2 versus group 1 (17 ± 7 minutes vs 30 ± 11 minutes; P = 0.001). The rate of crossing failures was 0% with use of the floppy pigtail guidewire as well as with the traditional technique. No complications were observed with use of the floppy pigtail guidewire.

Conclusions

Utilization of a thin, floppy pigtail guidewire for left atrium access is safe and markedly accelerates insertion of the SG for the MitraClip^®‐procedure without crossing failures of the atrial septum. (J Interven Cardiol 2015;28:472–478)

     

Percutaneous Retrograde Recanalization of a Chronic Total Coronary Artery Occlusion in a 7 Year Old

The arterial switch operation for correction of transposition of the great arteries can be complicated by late stenosis or occlusion of the coronary arteries that are re-implanted to the new aorta. We report the case of a young boy who underwent this operation as a neonate and was found to have an occluded anomalous left anterior descending artery (LAD) before age 3. Subsequent bypass surgery was complicated by anastomotic stricture and kinking of the left internal mammary artery graft to the LAD. At age 7, the LAD territory showed reversible ischemia on nuclear perfusion testing and he was referred for percutaneous coronary intervention. A combined approach with pediatric and adult interventional cardiologists resulted in successful retrograde PCI to recanalize the chronic total occlusion of the LAD. Important features of this technique in pediatric patients are discussed.     

Successful Radiofrequency Catheter Ablation in a Patient with Wolff-Parkinson-White Syndrome after Unsuccessful Surgical Repair

Radiofrequency catheter ablation has found wider applications for the treatment of supraventricular and ventricular tachycardias. We present a case report of a 30-year-old woman with a history of Wolff-Parkinson-White syndrome and surgical excision of both septal and paraseptal accessory pathways. Five years post-surgery, she presented with recurrent supraventricular tachycardia. Subsequently, she underwent successful radiofrequency catheter ablation of a right posterior septal accessory pathway. After 1.8 seconds of 20 watts of radiofrequency energy delivered to the right posteroseptal region (coronary sinus os), orthodromic supraventricular tachycardia was terminated. After completion of a full 100Dsecond application, there was no evidence of either manifest or concealed accessory pathways, and no supraventricular tachycardia upon restudy. This study emphasizes the ease and facility of the percutaneous catheter ablation techniques that are now employed as compared to the open chest surgical approach.     

Impact of Successful Chronic Coronary Total Occlusion Recanalization on Recurrence of Ventricular Arrhythmias in Implantable Cardioverter-Defibrillator Recipients for Ischemic Cardiomyopathy (VACTO PCI Study)

BackgroundCoronary chronic total occlusion lesions (CTOs) confer an increased risk of arrhythmic events among patients with ischemic cardiomyopathy (ICM) and implantable cardioverter-defibrillator (ICD) carriers, however the impact of CTO recanalization in this population remains unassessed.AimsEvaluate the impact of CTOs percutaneous coronary interventions (PCI) on arrhythmic events.MethodsPatients with ICM and ICD from the VACTO I-II registries: patients with medically treated CTO (CTO-OMT group) and without CTO (no-CTO group) were compared after inverse-probability-weighting adjustment (IPWT) with a similar population of consecutive patients undergoing CTO-PCI. The primary endpoint was appropriate ICD therapy. The secondary endpoint was all-cause mortality.ResultsThe total of 622 patients (mean age 67 ± 10 years, mean left ventricular ejection fraction 36 ± 11%) included in the analysis was composed by: CTO-PCI patients n = 113, CTO-OMT patients n = 286, no-CTO patients n = 223. In the CTO-PCI group, compared to the CTO-OMT group, 5-year Kaplan Meier estimates for appropriate ICD therapy (20.4% vs. 56.4%, IPW-adjusted HR: 0.45, 95% CI 0.29–0.71) and mortality (8.8% vs. 23%, IPW-adjusted HR: 0.43, 95% CI 0.22–0.85) were lower, driven by infarct related artery CTO (IRA-CTO) PCI, while similar to those occurring in the no-CTO group.ConclusionsIn this large population, those with CTO receiving PCI had lower arrhythmic event rates and lower mortality compared to the CTO-OMT group, while showing an event rate similar to no-CTO patients. Sensitivity analyses suggest that the beneficial effect on the arrhythmic outcome was driven by IRA-CTO revascularization.ClassificationChronic total occlusion.     

Coronary Stenting in Vessels with Marked Proximal Tortuosity Using a Sport Wire: Advantages and Pitfalls

In this report two patients are described in whom successful deployment of a coronary stent was achieved in a very tortuous coronary artery. Deployment was performed using a special extra-support wire that straightened the proximal segment of the artery and provided the support for stent advancement. The mechanical straightening of the artery induced marked narrowing that did not respond to intracoronary nitroglycerin but disappeared after withdrawal of the wire.     

Subselective Intracoronary Access Guide Catheters for use with the ProbeTM Balloon on a Wire Coronary Dilatation Device

Subselective coronary access guide catheters are described for use with the Probe^TM balloon on a wire coronary dilatation device. These access catheters provide the following advantages over the "naked" Probe^TM: (1) Guide catheter stabilization, (2) Lesion access, (3) Lesion visualization, (4) Lesion crossing, and (5) Lesion protection. The Probe/access catheter system was used in 51 patients on 132 lesions (average 2.6 lesions/patient; range 1–8 lesions/patient) of which 116 (88%) were dilated successfully. Failures tended to be in total occlusions or in eccentric subtotal occlusions that could not be crossed with the Probe^TM tip wire. No patient required emergency coronary bypass. One patient sustained a small myocardial infarction within 24 hours of the procedure. One patient developed hemopericardium after rupture of a small branch coronary artery. One patient died from intracerebral bleeding due to thrombolytic and anticoagulant therapy. The Probe^TM access catheter system has several advantages over the Probe^TM device alone, and future developments can be expected to extend these benefits. (J Inter-ven Cardiol 1989:2:1)