Recanalization of chronic total coronary arterial occlusions by percutaneous excimer-laser and laser-assisted angioplasty

A low primary success and high restenosis rate after recanalization of chronic total occlusions by conventional coronary angioplasty have encouraged the application of new interventional techniques like excimer-laser angioplasty. In 39 patients with a coronary occlusion for 1 to 12 months, recanalization was attempted by laser angioplasty through a multifiber-catheter coupled to a pulsed XeCl excimer laser. After successful passage of the occlusion by a standard guidewire in 27 patients (69%), the laser catheter was advanced over the central guidewire and crossed the occlusion in 25 patients (64%). In 2 patients with unsuccessful passage of the laser catheter, the subsequent attempt with a low profile balloon catheter also failed. In 19 of the 25 patients with successful laser recanalization, the residual stenosis exceeded 50% and was therefore followed by additional balloon angioplasty. The average residual stenosis after laser was 61 +/- 17% of the vessel diameter, and after balloon angioplasty 28 +/- 9% (n = 19), whereas after laser angioplasty alone it was 38 +/- 5% (n = 6). No complications associated with the laser application were observed. Angiographic control after 24 hours showed a reocclusion of 2 (8%) recanalized vessels. In this pilot study, laser angioplasty proved to be a safe and feasible method for the treatment of chronic total coronary occlusions. Because it was necessary to guide the catheter by a central wire, the primary success was limited by a successful passage of the wire of the occlusion. The rate of stand-alone laser angioplasty has to be increased by future improvements of the technique to enable a comparative evaluation of this method with conventional angioplasty.     

Rotation angioplasty of chronic coronary artery stenosis

Coronary artery occlusion of more than six months duration can only rarely be recanalized with conventional techniques. For this reason, rotational angioplasty, which has been successfully applied for occlusion of peripheral arteries, has been employed in modified form for recanalization of chronic coronary artery occlusion. Rotational angioplasty is based on the concept that the slowly revolving, dull and relatively thick head of the flexible rotation catheter will seek the path of least resistance which, even in the case of relatively old arterial occlusions, mostly represents thrombotic material. The elastic, high-torque rotational catheter constructed of several V2A spiral steel wires has an interior lumen for insertion of exchange guidewires up to 0.014" and injection of contrast medium and an olive-shaped head of V2A steel with a diameter of 1.3 to 1.6 mm. A protection catheter made of polyethylene with metal markers and conically-tapered tip provides variable stiffness of the rotating catheter and protection of the endothelium in the proximal vascular segment. The slow rotation of 200 r.p.m. is performed with a small electric motor. Between April 1987 and February 1988, rotation angioplasty was performed in 20 patients, 17 with occlusion of the right coronary artery, two with occlusion of the left anterior descending artery and one with bypass graft occlusion to the left anterior descending artery in whom a conventional guidewire through the chronic occlusion could not be advanced. The duration of occlusion, based on previous angiograms anginal complaints or myocardial infarction, ranged from one month to twelve years, in twelve patients more than six months. In all patients, the indication for revascularization was clearly established.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anchoring technique to improve guiding catheter support in coronary angioplasty of chronic total occlusions.

The primary reason for unsuccessful angioplasty of chronic total occlusions (CTOs) is an inability to pass the guidewire through the occlusion. Optimal guiding catheter support is a prerequisite for successful angioplasty of CTO. We performed guidewire manipulation by anchoring a balloon in a side-branch vessel in order to achieve adequate guiding catheter support. With this novel anchoring technique, we successfully achieved guidewire passage through the CTO.     

Successful Recanalization Using a Hydrophilic-Coated Guide Wire in Total Coronary Occlusions After Unsuccessful PTCA Attempts with Standard Steerable Guide Wires

During a balloon angioplasty procedure, cardiac interventionalists frequently have difficulty passing standard guide wires into coronary arteries with chronic total occlusion. In the past year, we encountered eight patients with occluded coronary arteries where standard guide wires were tried (average duration 15.5 minutes) but were unsuccessful. Application of a 0.025–0.035-inch hydrophilic guide wire was then attempted and was successful in recanalizing seven of the eight coronary occlusions (average duration 3.9 minutes). The channel created by the hydrophilic guide wire remained patent after its removal and permitted subsequent balloon angioplasty to be performed. Thus, in some patients with coronary occlusion where difficulty in guide wire passage is encountered, the application of a hydrophilic guide wire for crossing the occlusion and facilitating PTCA should be considered. However, a larger clinical series will be needed to determine the safety and efficacy of this technique.     

Use of the CrossBoss catheter for crossing superficial femoral artery chronic total occlusions

The CrossBoss chronic total occlusion catheter has been developed for the treatment of coronary chronic total occlusions. We report a novel use of the CrossBoss catheter for the crossing of a superficial femoral artery chronic total occlusion in three patients after conventional guidewire techniques failed.     

Early experience with low speed rotational angioplasty.

OBJECTIVE--Preliminary assessment of the efficacy and safety of the low speed rotational angioplasty catheter system (ROTACS). DESIGN--Open prospective trial. SETTING--Department of cardiology in a teaching hospital. PATIENTS--Eleven patients (10 with chronic stable angina and one with acute coronary occlusion after conventional angioplasty) in whom a coronary angiogram showed occlusion or critical stenosis of the coronary artery (right in seven patients, circumflex in two, and left anterior descending in two). The nature or severity of the lesion ruled out conventional coronary angioplasty. INTERVENTIONS--An attempt was made to cross the lesion with a rotating guide wire with a blunt swelling at its tip. Where necessary progress was assessed by simultaneous injection of contrast into both main coronary arteries. MAIN OUTCOME MEASURES--Progress of the ROTACS through the lesion that allowed a guide wire to pass into the distal vessel was regarded as a device specific success. When a guide wire crossed the lesion aided only by the support of the ROTACS without the use of rotation this was counted as a success that was not device specific. Failure to cross the lesion and any associated complications were noted. RESULTS--The ROTACS crossed only two of the 10 chronic lesions (20% device specific success rate); however, the support it provided enabled a guide wire to cross a further two lesions and allowed subsequent successful angioplasty in four of the 10 patients. One of these four patients presented after five months with recurrent angina requiring bypass grafting. The other three were symptom free at follow up seven months after the procedure. In the one patient with acute coronary occlusion the ROTACS was advanced over the guide wire to allow passage of an angioplasty balloon where this had previously proved impossible. An excellent final result was obtained and this patient remains symptom free. Three of the six patients in whom the ROTACS was unsuccessful had coronary artery dissection without sequelae. Three patients required subsequent elective coronary bypass grafting for control of symptoms while the other three remain well on medical treatment. CONCLUSIONS--The ROTACS may extend the range of patients with coronary artery occlusion or critical stenosis who can be treated non-surgically. The low device specific success rate (20%) achieved in this study indicates that it should be compared with other simpler mechanical devices that may be just as effective.     

Recanalization of chronic coronary occlusions by low speed rotational angioplasty (ROTACS)

From 1988 to 1990 chronic coronary occlusions were treated with a newly developed slowly rotating angioplasty system (ROTACS), which is designed for atraumatic passage of arterial obstructions. In all 152 patients (mean age 55 years, ranging from 29 to 78 years) attempts to recanalize the coronary occlusion with conventional guidewire systems had failed. In 74/152 patients the age of the occlusion could be estimated because of a previous angiogram or clinical event. It ranged from 1-192 months (median 6 months, mean value 14 months; in 20% of patients it was 1-3, in 37% 4-6, in 28% 7-12, and in 15% greater than 12 months). The occlusion was localized in the right coronary artery (RCA) in 86 cases, in the left anterior descending coronary artery (LAD) in 37 cases, and in the circumflex branch of the left coronary artery in 17 cases. Eleven bypass occlusions were treated. One patient had a LAD and RCA occlusion. Out of 152 patients 84 could be recanalized. The success rate rose with experience from 30% to 60%. It was 55% in the LAD, 52% in the RCA, 70% in the circumflex branch, and 63% in bypass grafts. The success rate in relation to the age of the occlusion was 93% in occlusions of 1-3 month duration, 74% in occlusions of 4-6 months duration, 52% in occlusions of 6-12 months duration, and 8% in occlusions older than 12 months. Seventy-six of the successfully treated patients underwent follow-up angiography after 4 months. In 56/76 (74%) the vessel remained open. Twenty-two patients (29%) had restenosis that was successfully dilated in 21 patients. Twenty patients (26%) had reocclusion. Thus, the angiographically determined long-term success rate was 72%. Emergency operation was necessary in two patients in whom reopening of the LAD was attempted although the occlusion was located directly at the take-off of the LAD from the left main. Since this type of occlusion was consequently considered a contraindication, no further serious complications occurred. There was one myocardial infarction, no death, no vessel wall perforation or other complications in the 152 patients. It is concluded that low speed ROTACS is a safe technique that can be applied in chronic coronary occlusions even if the duration of occlusion exceeds 6 months.     

Early clinical experience with a hot tip laser wire in patients with chronic coronary artery occlusions

Chronic coronary artery occlusions remain one of the problems limiting the use of percutaneous transluminal coronary angioplasty (PTCA). We have studied the use of an 0.018 inch laser hot tip wire. It was coupled either to a continuous wave argon or Nd-YAG laser generator and introduced through a balloon catheter to try and cross and dilate a series of chronic coronary artery occlusions in which initial conventional attempts had failed. Four LAD and 6 RCA occlusions were attempted; we successfully crossed and dilated 6 (60%) lesions, 4 (40%) using the laser wire alone to recanalize the occlusion and in 2 a combination of laser wire and conventional means.     

Results of low speed rotational angioplasty for chronic peripheral occlusions

After experimental investigation using postmortem human arteries, 19 patients with chronic peripheral artery occlusions were treated with a new angioplasty technique between December 1986 and October 1987. In 17 patients the superficial femoral artery and in 2 patients the popliteal artery were completely occluded. The length of the occlusions ranged between 5 and 25 cm (mean 11). The duration--estimated according to patients' history--was 5 to 48 months (mean 17). In 5 patients, durations of up to 30 months had been documented by angiography. A flexible, blunt, motor-driven rotating catheter was introduced through an 8 or 9Fr sheath and rotational angioplasty was performed at low speeds (up to 200 rpm). In 11 of 14 patients in whom this new technique was used as the primary intervention, the occlusions could be successfully reopened. In 2 patients after failure of conventional techniques the rotating catheter could not bypass the preexisting dissections in the same intervention. In 2 of 3 further patients after failure of conventional techniques the occlusions could be successfully reopened in a second intervention after several weeks. In none of the 19 patients did a perforation occur. It is concluded that with the new technique chronic peripheral artery occlusions can be reopened with a high success rate and without the danger of arterial wall perforation. The method can also be used in patients in whom conventional techniques have failed.     

Probe exchange catheter used for angioplasty of total coronary artery occlusions

Percutaneous transluminal coronary angioplasty (PTCA) for total occlusions frequently fails, because the guidewire fails to pass the occlusion. With the use of the Probe exchange catheter (PEC), however, stiffness of the guidewire is increased and a higher pushability is obtained in order to manipulate the guidewire beyond the lesion. Once the guidewire has passed, the PEC is advanced and a non-over-the-wire dilatation catheter can be introduced through the PEC. This paper describes the technique in a representative case. The results of this technique in 19 consecutive patients with class III-IV/IV(NYHA) angina due to an occluded coronary artery are presented. In 16 patients the PEC reached the lesion (84%) and in all these patients the guidewire could pass the occlusion. A successful PTCA was performed in 14 patients (74%).     

Angioplasty at coronary bifurcations: single-guide, two-wire technique

A technique is described for angioplasty at coronary bifurcations. This simple approach utilizes a single guiding catheter, an exchange wire, and a conventional dilatation catheter and guidewire. With this "protective" guidewire technique, side branches at risk from occlusion during dilatation of a primary coronary segment can be protected and dilated secondarily; continual access to the threatened side branch is maintained with a "standby" exchange wire in the branch vessel.     

Probe angioplasty of total coronary occlusion using the Probing Catheter technique

Coronary angioplasty (PTCA) of total coronary occlusion is limited by the inability of guidewires and conventional dilating catheters to cross all such lesions. A new technique was therefore prospectively evaluated for PTCA of these lesions using the ultra-low-profile Probe "balloon on a wire" device. An intracoronary Probing Catheter was used to facilitate crossing the stenosis with a guidewire and then to deliver a Probe into the obstruction for balloon dilatation. This technique was utilized in 64 consecutive patients with "absolute" coronary occlusions demonstrating no angiographically detectable antegrade coronary flow. Successful dilatation was achieved in 47 (73%). Among 33 occlusions of less than 3 mo duration 31 (94%) were successfully dilated whereas only 16 of 31 more chronic occlusions were dilated (P less than .01). Chronic occlusions with a tapered morphology and those located more than 1 cm from a branch point were more frequently dilatable. There were no serious complications including no vessel perforations with this technique. The Probing Catheter technique offers a safe and effective method for the dilatation of recent coronary occlusions by using balloon on a wire technology.     

Rotation angioplasty--initial clinical results of peripheral vascular occlusions

After experimental investigations in postmortem human arteries, 19 patients with chronic peripheral artery occlusions were treated with a new technique between December 1986 and October 1987. In 17 patients the superficial femoral artery, and in two patients the popliteal artery, was completely occluded. The length of occlusions were between 5 and 25 cm (mean 10.9 cm); the duration (estimated according to patient's history) was 5-48 months (mean 17.2 months). In five patients, durations of up to 30 months had been documented by angiography. A flexible, blunt, motor-driven rotating catheter was introduced over an 8 or 9 F sheet and rotational angioplasty was performed at low speed, up to 200 rpm. In 11/14 patients in whom this new technique was used as the first attempt, the occlusions could be successfully reopened. In two patients after failure of the conventional technique the rotating catheter could not bypass the preexisting dissections in the same intervention. In 2/3 further patients after failure of the conventional technique the occlusions could be successfully reopened in a second intervention after several weeks. In none of our 19 patients did a perforation occur. It is concluded that by using the new technique, chronic peripheral artery occlusions can be reopened with a high success rate and without the danger of vessel wall perforation. The method can also be applied in patients in whom conventional techniques have failed.     

High frequency rotational ablation: an alternative in treating coronary artery stenoses and occlusions.

OBJECTIVE--To prove the safety and effectiveness of high frequency rotational ablation of coronary artery stenoses and occlusion in humans. SUBJECTS--106 patients with symptoms (91 men, 15 women) who had 67 significant stenoses, mainly types B and C, and 46-chronic occlusions. MAIN OUTCOME MEASURES--Mean change in diameter stenosis after rotational angioplasty alone and in combination with percutaneous transluminal coronary angioplasty immediately after treatment and 24 hours and six months later; restenosis rates at six months; complication of treatment. RESULTS--Rotational ablation could not be used in five stenoses and 16 chronic occlusions because of inability to reach or cross the lesion with the Rotablator guide wire. In four cases rotational ablation failed. Initial angiographic and clinical success by rotational ablation was achieved in 40 of the 67 stenoses (60%) and in 18 of the 46 chronic occlusions (39%). Additional balloon angioplasty was performed in 45 patients, increasing the success rates to 79% and 54%, respectively. In the 62 stenoses treated by rotational ablation the angiographic diameter stenoses were reduced from 76% (SD 14%) to 32% (14%) after Rotablator treatment alone and from 75% (11%) to 33% (17%) with additional balloon angioplasty. In the 30 chronic occlusions treated by rotational ablation the angiographic diameter stenoses were reduced to 38% (18%). At six months angiographic restenosis was evident in nine of the 25 (36%) stenoses treated with rotational ablation alone, in seven of the 22 (32%) stenoses treated with rotational and balloon angioplasty, and in 14 of the 24 (58%) chronic occlusions. There were no procedural deaths and two patients (2%) underwent emergency coronary artery bypass grafting. Although no transmural infarction occurred, there were five (6%) non-Q wave infarctions (two embolic side branch occlusions, two subacute occlusions, and one acute occlusion). Clinically insignificant slight increases in creatine kinase activity were seen in five patients (6%). Severe coronary artery spasm unresponsive to medical treatment was provoked in seven cases (8%). CONCLUSIONS--High frequency rotational ablation is a safe and effective method for treating type B and C coronary artery lesions with results comparable to percutaneous transluminal coronary balloon angioplasty. The combined use of rotational ablation and balloon angioplasty is feasible and is necessary in about half of all procedures, in most cases because the lumen created by the biggest burr is too small.     

Intraluminal blunt microdissection for angioplasty of coronary chronic total occlusions.

This study describes a new approach to crossing coronary chronic total occlusions using controlled blunt microdissection and its successful application to coronary angioplasty in three patients. After guidewire techniques failed to cross the occlusions, the blunt intraluminal microdissection catheter was deployed. Actuation of a hinged jaw on the catheter distal assembly created a channel for the guidewire through the diseased segment, in the true lumen (a right coronary and a left circumflex artery) and subintimally (a circumflex artery), to allow angioplasty and stenting. Coronary circulation improved from TIMI grade 0 to 3. Angina was relieved in all three cases. Subsequent angiography for two cases, 2 and 19 months after PTCA, respectively, showed restored flow and patent stented regions.     

Magnum wire for balloon recanalization of chronic total coronary occlusions

A new guidewire (Magnum wire, Schneider) was developed for balloon recanalization of chronic total coronary occlusions. This 0.021-inch solid-steel wire with a floppy tip equipped with a 1-mm diameter "olive" is used like an ordinary guidewire, fits conventional balloon catheters and provides excellent steerability. Magnum wires were used in 50 consecutive chronic total coronary occlusions (mean +/- standard deviation duration 8 +/- 21 months, range 1 day to 10 years; mean length 1.1 +/- 0.8 cm, range 0.2 to 4.0). All occlusions were reached (in 23 right, 18 left anterior descending, 8 left circumflex coronary arteries and 1 diagonal branch) and 30 (60%) were recanalized (1 reoccluded during the procedure, and in 3 patients the Magnum wire did not completely cross the occlusion but enabled the previously impossible passage of a conventional wire). The mean age of the occlusion was 3 +/- 4 months in successful and 17 +/- 33 months in unsuccessful procedures (p = 0.04) and the mean length was 1.1 +/- 0.9 and 1.3 +/- 0.6 cm, respectively (p = 0.4). In 17 patients, conventional techniques had been exhausted before the Magnum wire attempt, which was successful in 8 (47%). In 33 patients the Magnum wire was tried first, with success in 22 (67%). Conventional techniques were subsequently tried in 9 of the 11 failures (none was successful). Of the 38 procedures carried out with a second, improved version of the Magnum wire, 26 (68%) were successful.(ABSTRACT TRUNCATED AT 250 WORDS)     

Probe™ angioplasty of total coronary occlusion using the probing catheter™ technique

Coronary angioplasty (PTCA) of total coronary occlusion is limited by the inability of guidewires and conventional dilating catheters to cross all such lesions. A new technique was therefore prospectively evaluated for PTCA of these lesions using the ultra-low-profile Probe? “balloon on a wire” device. An intracoronary Probing Catheter? was used to facilitate crossing the stenosis with a guidewire and then to deliver a Probe? Into the obstruction for balloon dilatation. This technique was utilized in 64 consecutive patients with “absolute” coronary occlusions demonstrating no angiographically detectable antegrade coronary flow. Successful dilatation was achieved in 47 (73%). Among 33 occlusions of less than 3 mo duration 31 (94%) were successfully dilated whereas only 16 of 31 more chronic occlusions were dilated (P<.01). Chronic occlusions with a tapered morphology and those located more than 1 cm from a branch point were more frequently dilatable. There were no Serious complications including no vessel perforations with this technique. The Probing Catheter? technique offers a safe and effective method for the dilatation of recent coronary occlusions by using balloon on a wire technology.     

Angioplasty of chronic total coronary occlusions with the use of six French guiding catheters

The efficacy of 6 French guiding catheters for angioplasty of chronic total coronary occlusions was evaluated in 61 consecutive patients. The duration of the occlusion was determined angiographically, or estimated from an index clinical event. Endpoints were procedural success, defined as recanalization with less than 50% residual stenosis without major complications; and the need to change to larger-sized guiding catheters. Recanalization was attempted in 62 chronic total occlusions; 35 were located in the left anterior descending coronary artery, 18 in the right coronary artery, and 9 in the left circumflex coronary artery. The mean duration of the occlusion was 6.0 ± 6.6 months; the range was 2–39 months. Lesion morphology included abrupt or diffuse occlusion (55%), a side branch originating at the occlusion (47%), and bridging collaterals (23%). Death, urgent coronary bypass surgery, or myocardial infarction did not occur. Recanalization was successful in 51 of the 62 total occlusions (82%); 49 were completed successfully with a 6 French guiding catheter, and 2 were successful after changing to a larger-sized guiding catheter (which was required for peripheral vessel tortuosity in one patient, and to obtain better back-up support in another). Three other attempts remained unsuccessful after a changing. A total of 12 Palmaz-Schatz stents were implanted in 11 patients for an unsatisfactory result or type C dissection, using the same 6 French guiding catheters. These preliminary findings indicate that 6 French guiding catheters are both effective and safe for angioplasty of chronic total occlusions. Cathet. Cardiovasc. Diagn. 40:255–260, 1997. © 1997 Wiley-Liss, Inc.     

Rotacs: a device used in coronary and peripheral arterial recanalization]

The authors report their preliminary results with the Rotacs system in the reopening of chronic coronary artery occlusion by low-speed rotational angioplasty. This system improves the percentage of coronary recanalisation in cases where it is impossible to pass the guide wire alone. It seems to be an effective, low-cost complementary tool for the treatment of this type of lesion.     

Recanalization of chronic total coronary occlusions: the impact of a new specific guidewire on primary success rate

BACKGROUND: Although chronic total occlusions are encountered frequently in patients with coronary artery disease, an effective strategy to deal with them has yet to be devised. Various new guidewires have been designed in an attempt to negotiate chronic occlusions successfully. The authors have analysed the impact of the Athlete guidewire on procedural success in this lesion subset. METHODS: Sixty-two consecutive patients undergoing percutaneous intervention for chronic total occlusions over a twoyear period were retrospectively studied. For the initial attempt, conventional guidewires were used. In case of failure, further attempts were made using the Athlete guidewire. Procedural success rates with the use of conventional and Athlete guidewires were assessed. RESULTS: Failure of the first attempt with the conventional guidewire occurred in 32 (51.6%) patients and success was achieved in 30 (48.4%) patients. In the former patients, a second attempt was made using the Athlete guidewire to cross the occlusion. The second attempt was successful in 20 patients (60%) in whom the first attempt was unsuccessful, while in the remaining 12 (40%) patients the occlusion could not be crossed even during the second attempt and the procedure was then terminated. Following the use of the Athlete guidewire, the success rate increased to 62% ( p < 0.001). No complication occurred during the first attempt, while one patient had a coronary perforation using the Athlete guidewire, which was managed successfully without the need for bypass surgery. CONCLUSION: The use of the Athlete guidewire is feasible and safe, and enhances the chances of successfully treating chronic total occlusions during percutaneous coronary revascularization procedures. (Int J Cardiovasc Intervent 2000; 3: 105-110)