STAR procedure becomes SAFER: First-in-man case series of a new antegrade dissection re-entry technique

Introduction

Antegrade dissection and re-entry (ADR) is an integral part of the hybrid algorithm, which has allowed for improved outcomes in chronic total occlusion (CTO) coronary intervention (PCI).

Methods

A new ADR method, Subintimal Antegrade FEnestration and Re-entry (SAFER), is described. The results of a first-in-man series are presented.

Results

SAFER was performed on seven consecutive patients with angiographic and clinical success in all patients.

Conclusions

This first-in-man study has shown that the SAFER technique is feasible and effective with the possibility of improving the antegrade PCI CTO success rate.     

A new combined antegrade and retrograde approach for chronic total occlusion recanalization: Facilitated antegrade fenestration and re-entry

While antegrade techniques remain the cornerstone of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), operators have often to resort to the retrograde approach in complex occlusions. In particular, lesions with proximal cap ambiguity, unclear vessel course and/or poor distal landing zone are difficult to tackle with either antegrade wiring or antegrade dissection and re-entry (ADR), and often require the retrograde approach. After collateral channel crossing, the retrograde approach usually culminates with either reverse controlled antegrade and retrograde subintimal tracking (CART) or retrograde true lumen crossing. Both techniques usually involve the use of an externalization wire, which requires keeping a higher activate clotting time to prevent thrombosis of the retrograde channel and is potentially associated with risk for donor vessel injury. In 2018, we described antegrade fenestration and re-entry (AFR), a targeted ADR technique in which fenestrations between the false and true lumen are created by antegrade balloon dilatation in the extraplaque space at the level of the distal cap, which are subsequently engaged by a polymer-jacketed wire to achieve re-entry. We hypothesized that AFR can also expedite antegrade crossing of the CTO after a wire has reached the distal vessel in a retrograde fashion. In this report, we present two cases in which we successfully achieved antegrade CTO crossing with AFR following retrograde advancement of a guidewire to the distal cap, in new variant of the technique, which we called “facilitated AFR”.     

Corsair微导管辅助Stingray球囊正向夹层再进入技术开通冠状动脉慢性完全闭塞病变的应用研究

目的探讨改良性BridgePoint系统即Corsair微导管替代CrossBoss导管辅助Stingray球囊的正向夹层再进入技术开通冠状动脉慢性完全闭塞(CTO)病变的安全性及有效性。方法对2016年6月至2019年9月空军军医大学第一附属医院连续应用Corsair微导管替代CrossBoss导管辅助Stingray球囊的正向夹层再进入技术尝试开通45例CTO病变患者的安全性、有效性进行分析。结果45例患者中男性41例(91.1%),平均年龄(58.5±12.6)岁,日本多中心CTO注册研究评分(J-CTO)为(2.42±0.75)分,均为补救性正向夹层再进入技术开通病变,均采用改良性BridgePoint系统即Corsair微导管替代CrossBoss导管辅助Stingray球囊的正向夹层再进入技术。40例(88.9%)开通成功,其中Corsair到位后调整导丝进入真腔3例,5例失败后通过其他正向技术或(和)逆向技术补救成功4例,导丝通过总体成功率为44例(97.8%)。2例围术期心肌梗死,均为非ST段抬高型心肌梗死;1例因边支闭塞行急诊介入再次血运重建,住院期间主要不良心血管事件(MACE)发生率为6.7%,手术成功42例(93.3%)。平均手术时间为(158±62)min,对比剂用量(452±167)ml。结论改良性BridgePoint系统即Corsair微导管替代CrossBoss导管辅助Stingray球囊的正向夹层再进入技术开通CTO病变成功率较高,安全可行。     

Initial experience with a dedicated coronary re-entry device for revascularization of chronic total occlusions

Objective : The aim of this registry was to evaluate a new device designed to facilitate antegrade guidewire re‐entry into the true lumen of a chronic total coronary occlusion (CTO) from the adjacent subintimal space. Background : Successful recanalization of CTOs results in clinical improvement in appropriately selected patients. CTO intervention is time‐ and resource‐consuming, and a simplified approach enabling antegrade guidewire re‐entry into the distal true lumen might improve success. Methods : Patients with CTO and ischemia were entered into a prospective registry regardless of lesion characteristics. If wire manipulation resulted in subintimal wire entrapment, a new re‐entry tool (a 2.5‐mm flat subintimal balloon with two exit ports offset by 180°) was used as a platform to attempt guidewire penetration into the distal true lumen. The primary endpoint assessed was successful device‐guided re‐entry. Standard techniques were then utilized to open the CTO. Results : In 40 consecutive CTO lesions attempted, 19 resulted in subintimal wire entrapment (mean occlusion length 44 mm). Sixteen of these 19 were successfully crossed with an antegrade guidewire into the distal true lumen using the new device (84%). One patient with unsuccessful re‐entry was subsequently recanalized with a retrograde technique. All crossed lesions were stented (17/17), resulting in TIMI 3 flow without major complications. Two cases were unsuccessful. One patient had a grade I coronary perforation requiring no treatment. Conclusions : A new device to recanalize CTOs complicated by subintimal wire entrapment can be used successfully by experienced operators. Further study of this coronary re‐entry device is ongoing. © 2011 Wiley Periodicals, Inc.     

Mini-STAR as bail-out strategy for percutaneous coronary intervention of chronic total occlusion

Background: Although the advancement of the equipment and the presence of innovative techniques, percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) continues to be affected by lower procedural success in comparison with non occluded vessel PCI. Objective: We describe a new technique for the treatment of coronary CTO which utilizes a new generation of polymeric wires. Methods and Result: From March 2009 to June 2010 different strategies were adopted as “bail out” after an initial attempt failed in 117 consecutive CTO lesions. Among these, conventional strategies (CS) such as parallel wire, sub‐intimal tracking and re‐entry (STAR), microchannel technique, intracoronary ultrasound guided revascularization and anchor balloon, were used in 75 cases (64.1%), while in the remaining a new technique, the “mini‐STAR,” was used (39.9%). Although no substantial differences were observed regarding the distribution of clinical features and angiographic lesions characteristics between the populations, mini‐STAR was able to achieve a higher rate of procedural success in comparison with other CS (97.6% vs. 52%, P < 0.001) with lower contrast agent use (442 ± 259 cm³ vs. 561 ± 243 cm³, P = 0.01) and shorter procedural and fluoroscopy times (122 ± 61 vs. 157 ± 74 min, P = 0.009 and 60 ± 31 min vs. 75 ± 38 min, P = 0.03, respectively). No differences were observed in term of peri‐procedural complications such as procedural myocardial infarction, coronary perforations, and contrast‐induced nephropathy between mini‐STAR and CS. Conclusion: The mini‐STAR technique is a promising strategy for the treatment of CTO lesions, achieving a high procedural success rate and low occurrence of procedural adverse events. © 2011 Wiley Periodicals, Inc     

Collateral grading systems in retrograde percutaneous coronary intervention of chronic total occlusions

Background

The Japanese Channel (J-Channel) score was introduced to aid in retrograde percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTOs). The predictive value of the J-Channel score has not been compared with established collateral grading systems such as the Rentrop classification and Werner grade.

Aims

To investigate the predictive value of the J-Channel score, Rentrop classification and Werner grade for successful collateral channel (CC) guidewire crossing and technical CTO PCI success.

Methods

A total of 600 prospectively recruited patients underwent CTO PCI. All grading systems were assessed under dual catheter injection. CC guidewire crossing was considered successful if the guidewire reached the distal segment of the CTO vessel through a retrograde approach. Technical CTO PCI success was defined as thrombolysis in myocardial infarction flow grade 3 and residual stenosis <30%.

Results

Of 600 patients, 257 (43%) underwent CTO PCI through a retrograde approach. Successful CC guidewire crossing was achieved in 208 (81%) patients. The predictive value of the J-Channel score for CC guidewire crossing (area under curve 0.743) was comparable with the Rentrop classification (0.699, p = 0.094) and superior to the Werner grade (0.663, p = 0.002). Technical CTO PCI success was reported in 232 (90%) patients. The Rentrop classification exhibited a numerically higher discriminatory ability (0.676) compared to the J-Channel score (0.664) and Werner grade (0.589).

Conclusions

The J-channel score might aid in strategic collateral channel selection during retrograde CTO PCI. However, the J-Channel score, Rentrop classification, and Werner grade have limited value in predicting technical CTO PCI success.     

Traditional antegrade approach versus combined antegrade and retrograde approach in the percutaneous treatment of coronary chronic total occlusions

Objectives : The goal of this study was to compare the antegrade‐approach and bilateral‐approach strategies for chronic total occlusion (CTO). Background: The retrograde approach has been reported for difficult CTO lesions. Methods : This study assessed 96 consecutive patients with 119 CTO lesions. The lesions were treated with either an antegrade approach (A group) or a combined bilateral antegrade and retrograde approach (B group). The specific intervention techniques, in‐hospital success rate, and major adverse cardiac and cerebrovascular events (MACCE) were compared. Results : Lesions with well‐developed septal collaterals with nontortuous microchannels were preferentially chosen for the B group versus A group (P < 0.001 and 0.008, respectively). Compared with the A group, there were more CTO lesions located in the right coronary artery in the B group (P < 0.001). In the B group, the CTO lesions had a longer length and needed stiffer wires for crossing than in the A group (P = 0.001 and 0.046, respectively). The technical success rate was 94% and 86% for the A group and the B group, respectively (P = 0.127). In‐hospital complications were not different between the two groups. The B group needed a higher radiation exposure dose and a greater exposure time than the A group (P < 0.001). In the B group, use of the retrograde method significantly increased the final success rate. Conclusions: These results suggest that all CTO lesions should first be managed with an antegrade approach. When there is difficulty crossing the lesion, switching to a bilateral approach is an option for lesions with well‐developed collaterals. © 2009 Wiley‐Liss, Inc.     

Subintimal guidewire tracking during successful percutaneous therapy for chronic coronary total occlusions: Insights from an intravascular ultrasound analysis

Objectives : We sought to determine the frequency of subintimal guidewire tracking during successful percutaneous coronary intervention (PCI) for chronic coronary total occlusions (CTOs) and to better understand the procedural implications of this event. Background : Successful PCI for chronic CTO is associated with improved outcomes in patients with ischemia. While subintimal guidewire tracking resulting in failure to cross is recognized as the major mode of failure for CTO PCI, the implications of subintimal guidewire tracking during successful CTO PCI are unknown. Methods : Between March 2007 and October 2007, 26 consecutive patients, each with one de‐novo CTO lesion successfully crossed with a guidewire were included in the analysis. Intravascular ultrasound (IVUS) was performed in each CTO vessel after guidewire crossing. Cases were classified as having definite subintimal wire tracking or no clear evidence of subintimal wire tracking based on analysis of IVUS images. Results : Subintimal wire tracking occurred in 45% of cases. In cases where subintimal wire tracking was present, a previous attempt at CTO PCI was more common (42% vs. 7%, P ≤ 0.05). Subintimal wire tracking was also associated with significantly longer final mean stent length (71 vs. 50 mm), procedure time (122 vs. 69 min), fluoroscopy time (47 vs. 22 min), and contrast dose (300 vs. 199 mL, P ≤ 0.05 for all). There was one perforation in the subintimal group which was successfully treated with stent placement. Conclusions : Subintimal wire tracking occurs frequently during successful PCI for CTO and is associated with increased lesion and procedural complexity.© 2011 Wiley Periodicals, Inc     

Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions.

OBJECTIVES: To investigate the feasibility and safety of the percutaneous dilatation of coronary septal collaterals and to allow its use as an access for retrograde approach to percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs). BACKGROUND: Despite improvements in percutaneous techniques and materials, CTO recanalization success rate is still suboptimal. The retrograde approach allows to significantly increase this success rate. However, its application via a bypass graft or epicardial collateral can potentially result in severe complications. A safer retrograde access is desired and would allow broadening the application of the retrograde approach in the percutaneous treatment of CTOs. METHODS: After a failed antegrade CTO recanalization attempt, a retrograde approach via septal collaterals was tried in 21 patients (19 males, 2 females). The septal collateral was accessed via the contralateral patent coronary artery and was crossed with a hydrophilic floppy wire. After successful wire crossing of the septal collateral, sequential low pressure dilatation was performed with a 1.25 or 1.5 mm balloon to allow the delivery of a balloon catheter up to the distal CTO site. RESULTS: Successful wire crossing and balloon dilatation of septal collaterals was achieved in 19 cases and in 17 cases, respectively. Postdilatation septal collateral diameter increased significantly reaching a mean diameter of 1.46 +/- 0.38 mm. Retrograde CTO recanalization was successfully performed in 71% of the cases. No major complications occurred. CONCLUSIONS: Coronary septal collaterals can be used as an access for the retrograde approach in the percutaneous treatment of CTOs.     

Percutaneous coronary interventions and cardiovascular outcomes for patients with chronic total occlusions

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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.