A comparison of the transradial and the transfemoral approach in chronic total occlusion percutaneous coronary intervention

Background: Transradial coronary intervention is a safe and effective method of percutaneous revascularization. Furthermore, the indications for transradial percutaneous coronary intervention (PCI) are expanding. However, there is limited data on the efficacy and the safety of the transradial approach for chronic total occlusion (CTO) PCI. Methods: We examined 468 patients who underwent CTO PCI between January 2003 and December 2005, and compared the radial (318 patients) and the femoral (150 patients) approach. Results: Baseline demographics, lesion location, and the vessel treated were similar in both groups. Angiographic success was 82% in radial versus 86% in femoral group, P = 0.28, similar in both groups. Total fluoroscopy time (24.49 ± 13.18 vs. 24.07 ± 14.12 min, P = 0.36), total procedure time (54.22 ± 25.35 vs. 60.23 ± 28.15 min, P = 0.23), and the use of total contrast volume (395.54 ± 180.25 vs. 406.15 ± 173.98 ml, P = 0.27) were similar in radial and femoral group, respectively. In hospital MACE [radial: 12 MI (3.8%) vs. femoral: 1 death (0.7%) and 5 MI (3.5%), P = 0.26] were similar in both groups. Access site vascular complications [radial: 11 (3.5%) vs. femoral: 17 (11.3%), P ≤ 0.001] were significantly less in radial group. Conclusions: The radial approach in CTO PCI is as fast and successful as the femoral approach with comparable in hospital MACE. However, there are far less access site complications with radial approach. © 2008 Wiley‐Liss, Inc.     

The retrograde approach to coronary artery chronic total occlusions: a practical approach

The retrograde approach has revolutionized the treatment of chronic total occlusions. Several retrograde techniques have recently been described. In this article, we present a practical review with step-by-step instructions on the indications for retrograde interventions, equipment and retrograde channel selection, and techniques for retrograde crossing and treatment of chronic total occlusions.     

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.     

A novel technique of chronic total occlusion retrograde wire crossing by wiring into the antegrade microcatheter

We described a novel transradial retrograde wiring technique to treat chronic total occlusion (CTO) of the left anterior descending artery. When both retrograde wire and kissing wire technique failed to cross the CTO lesion, an antegrade microcatheter was placed in the CTO lesion. Then, a retrograde wire was manipulated into the antegrade microcatheter and subsequently exchanged and wire externalized. This technique appears to be feasible and safe alternative for retrograde wire crossing of the CTO lesion. It is a less traumatic modified version of controlled antegrade and retrograde subintimal tracking (CART) technique that can be attempted before embarking on CART or reverse CART strategy. © 2010 Wiley‐Liss, Inc.     

成功开通慢性完全闭塞冠状动脉病变血管能提高患者的生存率

目的：观察慢性完全闭塞病变（chronic total occlusion,CTO）患者经皮冠状动脉介入治疗（percutaneous coronary intervention,PCI）成功对2年生存率的影响。方法： 连续入选2005年1月~2010年9月在我院心内科住院共700例稳定型心绞痛患者,其中84例（12%）为CTO患者。按照CTO病变成功开通组（开通组）或未成功开通组（未开通组）分层观察患者2年生存率。住院期间主要不良心脏事件（MACE）发生率,MACE包括心肌梗死、紧急血运重建、卒中或死亡。结果： 未开通组先前进行血运重建治疗的患者比例显著大于开通组（PCI分别为36% vs. 21%,P〈0.01）,两组的其他基线特征相似。术中并发症（包括冠状动脉夹层）在未开通组患者中更常见（分别为30.8% vs. 10.3%;P〈0.05）,但没有影响院内MACE事件发生率（分别为3%和2%,P〉0.05）。开通组2年生存率显著高于未开通组（96% vs. 83%,P〈0.01）。多因素分析显示手术成功为死亡概率的独立预测因子（HR：0.32,95% CI：0.18-0.58,P〈0.01）。结论：CTO病变PCI术后开通组的2年生存率较未开通组显著提高。     

Preliminary experience with the Frontrunner coronary catheter: novel device dedicated to mechanical revascularization of chronic total occlusions.

The novel device Frontrunner coronary catheter (FCC), dedicated to recanalization of chronic total occlusions (CTOs), relies on blunt microdissections inside the plaque, allowing passage of guidewire through the lesion and adjunctive angioplasty. In order to evaluate efficacy and safety of recanalization using the FCC device, we included patients with de novo or restenotic CTOs in a native coronary artery with prior failure using a guidewire or considered unsuitable for guidewire attempt in which the FCC was attempted first. Between October 2000 and June 2003, 50 patients with 50 CTOs were included in the study. Thirty-two patients had prior failure with a mechanical wire. Device and angiographic success were obtained in 25 (50%) occlusions: 53% in lesions with prior guidewire failure and 44% when FCCs were attempted first (P = 0.8). During the first year of experience, angiographic success was 42% (5 occlusions) and in the third year 75% (12 occlusions; P = 0.12). Coronary perforation occurred in nine (18.0%) patients, leading to tamponade in two (4%) patients. Perforations occurred in 5 out of 12 attempted patients during the first year and in 4 out of 38 patients in the following period (41.7% vs. 10.5%; P = 0.04). Serious adverse events occurred in five (10%) patients within 30-day follow-up. Four non-Q-wave myocardial infarctions occurred in hospital (clinical success 42%) and one death 7 days after the index procedure. The use of FCC increases the success to open chronic total occlusions refractory to mechanical guidewires or that were considered unsuitable for an attempt with a guidewire. The risk of coronary perforation due to FCC use is relatively high and it can decrease with experience.     

A case of successful angioplasty by the “double retrograde” approach for chronic total occlusion in the left circumflex artery

Currently introduced retrograde approach may increase the success rate of percutaneous coronary interventions on chronic total occlusion (CTO) lesion. This article describes a case of CTO in the left circumflex artery (LCX), which did not allow the regular retrograde approach to deliver a guide wire. At first, a guide wire was attempted to advance from the apical collateral channel, which supplied the distal LCX. However, wiring was extremely difficult because the collateral channel was headed reversely against the direction that the wire was going. Different angle angiogram revealed the existence of another collateral artery, which supplied the distal RCA (posterior descending branch). A guide wire was successfully advanced from the distal RCA, through apical collateral channel, and reached the distal LCX. After the wire was retrieved from the guiding catheter engaged in the left main trunk, antegrade access for balloon and stent delivery was obtained. This method, a sort of “double retrograde” approach, would be worthy to consider when recanalization is failed by other approaches. © 2011 Wiley Periodicals, Inc.     

Retrograde recanalization of chronic total coronary artery occlusion using a novel “reverse wire trapping” technique

Percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) remains a technical challenge for the interventional cardiologists. Recently, modified techniques based on the retrograde approach have demonstrated that this approach could increase the success rate for PCI of CTO. In the current report, we describe a novel “reverse wire trapping” technique that can help create an antegrade wire route to open CTO after the wire has passed through the CTO retrogradely, even though the retrograde balloon dilatation or antegrade wiring was unapproachable. © 2009 Wiley‐Liss, Inc.     

Double anchoring balloon technique for recanalization of coronary chronic total occlusion by retrograde approach

A retrograde approach through the collateral channels is considered to improve the success rate of percutaneous coronary intervention for coronary chronic total occlusion (CTO). Various kinds of strategies and techniques are required to improve the success rate of this novel approach. We describe a case in which a CTO was successfully recanalized by the retrograde approach, using a new anchoring balloon technique (double anchoring balloon technique) which enabled the successful balloon passage through the hard CTO lesion. © 2009 Wiley‐Liss, Inc.     

The confluent balloon technique for retrograde therapy of chronic total occlusion

Coronary chronic total occlusions (CTO) remain one of the most challenging lesions in percutaneous coronary intervention (PCI). Retrograde approach is an advanced PCI technique and can improve success rate in CTO intervention. Although success rate of this technique is high in experienced hands, there are still limitations in this approach, e.g., failure of wire to cross lesions. We report an easy and reliable new method of wire crossing in CTO lesions. In this technique, when both the antegrade and retrograde wires are in the subintimal space, balloons catheters are delivered in both directions to the site of the CTO. The balloons are then inflated simultaneously to create a common subintimal space (the confluent of subintimal space) which will allow crossing of wire to true lumen, either antegradely or retrogradely. This technique may improve the success rate of wire crossing and successful CTO intervention. © 2011 Wiley‐Liss, Inc.     

Initial experience and safety in the treatment of chronic total occlusions with fiberoptic guidance technology: optical coherent reflectometry.

Percutaneous treatment of chronic total coronary occlusions has been limited by procedural complications such as vessel injury or perforation. Optimizing visualization in the vessel with optical coherent reflectometry and a forward-looking fiberoptic guidance technology may improve the safety and efficacy of percutaneous treatment of these lesions.     

Crosswire™ for recanalization of total occlusive coronary arteries

Coronary angioplasty of total occlusions is technically difficult and is associated with limited success rates. The procedural outcome is mainly determined by the underlying pathological process. Recanalization of total occlusions is aimed at finding the passage with least resistance, without causing dissection or perforation. Several techniques have been advocated to improve the overall success rate. Recently, a new 0.014″ Nitinol wire (Crosswire™, Terumo) has been introduced as a tool, to achieve higher success rates for total occlusion angioplasty. The wire consists of an extremely flexible Nitinol-core, a platinum/iridium coil at the distal tip, and a hydrophilic polymer coating. Balloon angioplasty was attempted in 30 totally occluded coronary arteries with mean age of occlusion being 5 ± 4 months (range 2–14 months). The initial five procedures were performed following failure of the conventional angioplasty guidewires. Subsequently, Cross-wire™ was used electively in all the cases. The lesion was crossed successfully in 90% (27/30) cases. Dissection of the coronary artery with subintimal entry was seen in two (7%) cases, and the rest (three cases) could not be crossed. Balloon angioplasty and stenting (n = 21) were performed with good immediate angiographic results. There were no myocardial infarctions or deaths. Fourteen of 16 patients, who had completed 6 months follow-up, were asymptomatic. Angiographic evidence of in-stent restenosis was demonstrable in one case. Successful recanalization of total coronary occlusions by using Cross-wire™ can be expected in 83% cases, with reasonable safety. Cathet. Cardiovasc. Diagn. 45:323–327, 1998. © 1998 Wiley-Liss, Inc.     

Retrograde recanalization of a chronic total occlusion of a saphenous vein graft

Percutaneous revascularization of chronically occluded coronary arteries remains technically challenging, with far lower procedural success rates compared to other lesion subsets. Retrograde approach via septal collateral is more promising for improving success rates of this lesion in native coronary arteries. The potential benefits of successful treatment results in improvement in angina and mortality are well established. Occluded saphenous vein graft recanalization retrogradely has not been described before. We describe a case of retrograde recanalization of chronically occluded saphenous vein graft. © 2009 Wiley‐Liss, Inc.     

Transradial retrograde approach rescuing iatrogenic long spiral dissection during chronic total occlusion intervention

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is one of the greatest challenges in coronary interventions. A retrograde approach via the collateral channel has been recently proposed to improve the success rate of PCI in CTO lesions of the coronary arteries. We describe an accidental complication encountered during transradial PCI to recanalize right coronary artery CTO in a patient with unstable angina. A long spiral dissection has been created by antegrade wiring and extended from the ostium all the way down to mid RCA segment. Subsequent attempts with antegrade wiring into the true lumen were unsuccessful. Ad‐hoc retrograde recanalization has been employed to rescue the vessel via septal collateral from left anterior descending artery. Retrograde wiring and dilatation were performed followed by successful antegrade wiring into the true lumen under IVUS guidance, which revealed significant intramural hematoma extending distally to the posterolateral branch. Bailout stenting was achieved with sealing of the multiple entry and exit sites created by the spiral dissection and complete coverage of the intramural hematoma. This report highlights the role of the retrograde approach as a rescue option in the setting of complicated antegrade approach and to improve the success rate of CTO‐PCI. Moreover, IVUS was a valuable tool to confirm the true lumen course of the successful wire and to guide the stenting procedure. © 2012 Wiley Periodicals, Inc.     

老年冠状动脉慢性完全性闭塞病变患者行逆向介入治疗的可行性

目的 探讨老年冠状动脉慢性完全闭塞（CTO）病变的患者行逆向介入治疗的可行性。方法 选择2004年1月至2015年5月沈阳军区总医院心内科收治的行逆向介入治疗的≥60岁老年CTO患者119例（老年组）及同期行逆向介入治疗的＜60岁CTO患者136例（非老年组），对比分析两组患者逆向介入治疗手术成功率、治疗效果及并发症的发生率。结果 与非老年组比较，老年组更多合并高血压、糖尿病、脑血管疾病（均P＜0.05）；老年组欧洲心血管手术危险因素评分系统（EuroSCORE）评分明显高于非老年组（P＜0.001）。老年组合并双支和三支血管病变患者多于非老年组（均P＝0.000）；而老年组发生单支血管病变患者数低于非老年组（P＝0.000）。老年组SYNTAX评分高于非老年组，差异具有统计学意义（P＜0.001）。非老年组CTO时间为3～12个月的病例明显多于老年组，而老年组CTO时间为6～9年和＞9年的病例明显多于非老年组（均P＝0.000）。结论 本研究的结果表明逆向介入治疗对老年患者是安全有效的方法。     

Impact of ultra‐thin struts on restenosis after chronic total occlusion recanalization: Insights from the randomized PRISON IV trial

Objectives

The PRISON‐IV trial showed inferior outcome in patients with chronic total occlusions (CTOs) treated with the ultrathin‐struts (60 μm for stent diameter ≤3 mm, 81μm >3 mm) hybrid‐sirolimus eluting stents (SES) compared with everolimus eluting stents (EES, 81 μm). The aim of this study is to investigate if the use of smaller stents (≤3 mm) was responsible for the inferior outcome reported in the trial.

Methods

In the PRISON‐IV trial 330 patients with CTO lesion were randomized 1:1 to receive either hybrid‐SES or EES. The hybrid‐SES failed to reach the non‐inferiority primary endpoint of in‐segment late lumen loss (LLL) at 9‐month angiographic follow‐up. In this sub‐analysis, we divided the population according to the different size of stents implanted in those receiving only stents with diameter ≤3 mm (Group‐A, 178 patients), only stents >3 mm (Group‐B, 59 patients), and those receiving stents of both sizes (Group‐C, 93 patients).

Results

Baseline and procedural characteristics were comparable in the three groups. At angiographic follow‐up, most of the adverse outcomes occurred in Group A, with higher incidence of binary restenosis in the Hybrid‐SES versus EES (10.3% vs 1.3%, P = 0.03) and augmented in‐stent diameter stenosis (26.04 ± 18.59% vs 21.24 ± 12.84, P = 0.06). Similarly, optical coherence tomography (OCT), which was performed in 60 patients at follow‐up, documented a mild trend toward lower values of minimum in stent area in Hybrid‐SES arm of Group A (4.4 ± 1.02mm² vs 5.0 ± 1.28mm2, respectively, P = 0.16).

Conclusions

The present analysis suggests that the inferior performance of the ultra‐thin hybrid‐SES in CTO‐PCI is particularly pronounced when smaller stent (≤3 mm diameter) are adopted, if compared with EES.

     

Outcomes of percutaneous coronary intervention for chronic total occlusions in the elderly: A systematic review and meta‐analysis

ObjectiveThis study aimed to compare outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in the elderly (≥75 years) versus nonelderly and assess the impact of successful CTO‐PCI in the elderly.MethodsPubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched up to October 1, 2020. Mortality rates and major adverse cardiac events (MACE) were compared between elderly and nonelderly patients and successful versus failed CTO‐PCI in the elderly.ResultsEight studies were included. Meta‐analysis indicated no statistically significant difference in the risk of in‐hospital mortality (RR: 1.97 95% CI: 0.78, 4.96 I² = 0% p = .15) but higher tendency of in‐hospital MACE (RR: 2.30 95% CI: 0.99, 5.35 I² = 49% p = .05) in the elderly group. Risk of long‐term mortality (RR: 3.79 95% CI: 2.84, 5.04 I² = 41% p < .00001) and long‐term MACE (RR: 1.53 95% CI: 1.14, 2.04 I² = 80% p = .004) were significantly increased in the elderly versus nonelderly. Elderly patients had a significantly reduced odds of successful PCI as compared to nonelderly patients (OR: 0.63 95% CI: 0.54, 0.73 I² = 1% p < .00001). Successful CTO‐PCI was associated with reduction in long‐term mortality (HR: 0.51 95% CI: 0.34, 0.77 I² = 27% p = .001) and MACE (HR: 0.60 95% CI: 0.37, 0.97 I² = 53% p = .04) as compared to failed PCI in elderly.ConclusionsElderly patients may have a tendency of higher in‐hospital MACE with significantly increased long‐term mortality and MACE after CTO‐PCI. The success of PCI is significantly lower in the elderly. In elderly patients with successful PCI, the risk of long‐term mortality and MACE is significantly reduced.