A novel percutaneous coronary intervention technique for chronic total occlusion: Contralateral angiography with a single guiding catheter

We report two successful cases with a new percutaneous coronary intervention (PCI) technique to treat chronic total occlusion (CTO) by using contra‐lateral coronary angiography with a single guiding catheter (GC) safely. Firstly, a GC was inserted into the coronary artery supplying collaterals and a microcatheter was inserted into the distal side of the coronary artery. Then, the GC was retroflexed and engaged in the targeted coronary artery with CTO. While the contra‐lateral coronary artery was visualized by injection through a microcatheter, a guide wire was controlled and passed through the CTO lesion. Two sheaths insertion were necessary to perform contra‐lateral angiography in CTO PCI. This new technique makes it possible to perform safe contra‐lateral angiography with a single sheath and a single GC. It could reduce vascular access complication rates. © 2015 Wiley Periodicals, Inc.     

Transradial percutaneous coronary intervention for chronic total occlusion using sheathless technique and retrograde approach

The use of 5 or 6 Fr sheath in transradial (TR) approach is often required due to the relative small radial artery size. A sheathless approach may overcome the limitation of small radial size which limits the TR approach. Our case showed successful angioplasty of the right coronary artery chronic total occlusion (CTO) by bilateral TR approaches, utilizing a 7‐Fr guide (7 Fr BL 3.5, 85 cm) for a retrograde sheathless approach, and a 6‐Fr Ikari 3.5 guide catheter for an antegrade approach. The sheathless TR technique can minimize vascular trauma and increase back‐up support for successful coronary intervention in CTO.© 2013 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     

Percutaneous coronary intervention for chronic total occlusion: Novel 3‐dimensional imaging and quantitative analysis

Objective : The purpose of this study was to evaluate chronic total occlusion (CTO) lesions in three dimensions (3D) and to examine the potential yield and added diagnostic value of these reconstructions in planning percutaneous interventional procedures. Methods and Results : The novel CardiOp‐B system for 3D reconstruction of the coronary vessels was used in 302 angiographic images from 58 consecutive patients (86% men; mean age 62 ± 11 years) undergoing interventional treatment for CTO (61 CTOs). The success rate of 3D reconstruction was 83%. When successful, these reconstructions led to a significant improvement in lesion analysis, especially at the stump area and/or missing segment. Importantly, in 92% of the successful 3D reconstructions, the artery path in the lesion area could be delineated. In 95% of cases, in which post‐stenting 3D reconstruction performed, the vessel path was similar to the lesion path suggested before stenting. The mean stenosis area was significantly smaller in the 3D reconstructions vs. 2D images (94 ± 5.1% vs. 99 ± 0.3%, P < 0.001), and the mean lesion length was significantly shorter (15.3 ± 7.4 mm vs. 20.9 ± 8 mm, P < 0.001). Conclusions : In most cases, 3D reconstruction of CTOs can clearly image the stump area, delineate the lesion path, and provide enough information for the clinician to precisely calculate the severity of stenosis and lesion length. 3D reconstructions may serve as a useful tool for planning interventional procedures for CTOs and improving their success rate. © 2008 Wiley‐Liss, Inc.     

Drug‐coated balloon after subintimal plaque modification in failed coronary chronic total occlusion percutaneous coronary intervention: A novel concept

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is a technically challenging procedure. In failed cases, plaque modification strategy (also known as “investment procedure”), defined as the intentional dilation of the subintimal space through the CTO segment, can be applied. The typical dilation device used in this strategy is a regular angioplasty balloon (either semi‐ or noncompliant). Performing this technique with a drug‐coated balloon (DCB) may facilitate a staged procedure by promoting a better vessel healing. Herein, we present three cases of failed CTO PCI, managed with DCB plaque modification, and their follow‐up staged procedure.     

Contrast modulation in chronic total occlusion percutaneous coronary intervention

The intraplaque injection of contrast media in the recanalization of coronary chronic total occlusions (CTO) has witnessed a dynamic journey since its initial formulation. Contrast‐guided subintimal tracking and re‐entry (STAR) was the first contrast modulation technique for CTO percutaneous coronary intervention (PCI). With this technique, a forceful injection of a large volume of contrast (3–4 mL) was performed in order to achieve hydraulic recanalization of the vessel. This approach was associated with extensive vessel injury and unpredictable true lumen re‐entry, which were in turn linked to high rates of restenosis on follow‐up. In the subsequent iteration, called the “microchannel technique”, a smaller amount of contrast media (1 mL) was gently injected inside the plaque to modify its compliance by softening and recruiting loose tissue, which facilitated subsequent true‐to‐true lumen crossing with a polymer‐jacketed wire along paths of least resistance. The microchannel technique has later evolved into what is currently known as the “Carlino technique”, where a minimal volume of contrast media (<0.5 mL) is gently injected inside the occlusion, with the goal of modifying plaque compliance to facilitate guidewire and microcatheter advancement through a fibrocalcific plaque. The Carlino technique is now widely utilized to allow negotiation of difficult‐to‐cross occlusions, particularly by the “hybrid operators”, with high success rates and low incidence of complications. The purpose of this article is to provide a historical perspective on the use of contrast modulation in CTO PCI, its pathophysiological basis, as well as technical recommendations on how and when to perform these maneuvers.     

ViewIT improves intravascular ultrasound‐guided wiring in coronary intervention of chronic total occlusion

Terumo intravascular ultrasound (IVUS) ViewIT facilitates IVUS‐guided wiring in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) due to its low profile and surface coating. In PCI for CTO, the first guidewire is sometimes inserted into the subintimal space, and observation by IVUS through the first guidewire in the subintima can allow the second guidewire to be led visually into the true lumen. We describe a case of CTO in which ViewIT was inserted into the subintimal space of the CTO lesion and scanning from the coronary ostium to the CTO subintimal space allowed the second guidewire to be led into the true lumen. © 2010 Wiley‐Liss, Inc.     

Retrograde chronic total occlusion percutaneous coronary intervention using single catheter: A single centre registry

ObjectivesTo analyse the feasibility, safety and procedural outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) through retrograde approach using single catheter.MethodsOur study was a retrospective observational study that enrolled patients who underwent retrograde CTO PCI using a single catheter between June 2016 and February 2020. Clinical success was defined as successful completion of CTO PCI without associated in-hospital major clinical complications like death, myocardial infarction, stroke or urgent revascularisation. Technical success was defined as successful completion of CTO PCI using single catheter and minimum diameter stenosis of <30% with thrombolysis in myocardial infarction (TIMI) flow grade 3, without significant side branch occlusion, flow-limiting dissection, distal embolization, or angiographic thrombus.ResultsTotally 102 patients underwent retrograde CTO PCI during the study period. Out of which, 15 cases were attempted using single catheter. Mean age of the population was 59.1 ± 8.9 years (males: 86.7%) and the left ventricular ejection fraction (LVEF) was (61% ± 9.1%). Mean number of diseased arteries was 2.1 ± 0.7, length of the CTO was 25.5 ± 7.4 mm and J-CTO score was 2.3 ± 0.7. We achieved a technical success rate of 73.3% using single catheter, and the overall clinical success (Including single catheter and ping pong) was obtained in 86.7% cases. One patient (6.7%) developed cardiac tamponade and none of study population required dialysis for contrast induced acute kidney injury (CI-AKI)ConclusionsRetrograde CTO PCI using single catheter is a technically challenging procedure when compared with other CTO PCI. Our study demonstrated acceptable outcomes which is comparable to other antegrade and retrograde CTO PCI registries.