Intravascular ultrasound‐guided retrograde wiring for chronic total occlusion

This report describes a retrograde wiring technique, using intravascular ultrasound, for a blunt chronic total occlusion with a side branch at the site of occlusion of which the operator has difficulty of awareness of the proper re‐entry point with the retrograde wire angiographically. © 2009 Wiley‐Liss, Inc.     

A new retrograde wiring technique for chronic total occlusion

To improve the success rate of percutaneous coronary intervention for coronary chronic total occlusion (CTO), different strategies of retrograde approach were introduced in recent years. The aim of this report is to describe a new retrograde wiring technique for CTO, the “Bridge or Rendezvous method.” This new technique saves time, reduces cost, as well as reduces procedure‐related complications. © 2009 Wiley‐Liss, Inc.     

Drug-eluting stent-supported percutaneous coronary intervention for chronic total coronary occlusion.

OBJECTIVES: This study sought to determine the clinical and angiographic outcomes after drug-eluting stent (DES)-supported percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO). BACKGROUND: There are few data about the efficacy of DES-supported PCI for CTO. METHODS: All consecutive patients who had a sirolimus-eluting stent or a paclitaxel-eluting stent implanted for CTO from December 2003 to December 2004 were analyzed. Clinical and angiographic outcomes of patients treated with DES were compared with a case-matched control group of patients treated with bare metal stents (BMS) in the 12 months before the routine use of DES. RESULTS: Successful DES-supported PCI was performed in 92 patients and 104 CTO. The case-matched control group consisted of 26 patients and 27 CTO successfully treated with BMS. There were no differences between groups in baseline clinical and angiographic characteristics. Stent length in the DES group was higher as compared with that of BMS group (51+/-28 mm vs. 40+/-19 mm, P=0.073). The 6-month major adverse cardiac event (MACE) rate was lower in the DES group as compared with that of BMS group (9.8% vs. 23%, P=0.072). The angiographic follow-rate was 80% in the DES group and 81% in the BMS group. The 6-month restenosis rate was 19% in the DES group and 45% in the BMS group (P<0.001). By multivariate analysis, it was found that in the DES group, the only predictors of restenosis were stented segment length (OR 1.031, 95% CI 1.01-1.06, P=0.009) and a target vessel reference diameter<2.5 mm (OR 6.48, 95% CI 1.51-27.83, P=0.012), while the only predictor of MACE was stent length (OR 1.04, 95% CI 1.01-1.08, P=0.006). CONCLUSIONS: DES implantation for CTO decreases the risk of mid-term restenosis and MACE. Small vessels and diffuse disease requiring the implantation of multiple stents and very long stents for full coverage of the target lesion are still associated with a relatively high risk of restenosis.     

Intravascular ultrasound guided wiring re‐entry technique for complex chronic total occlusions

Background

The successful recanalization rate of chronic total occlusion (CTO) lesions without retrograde collaterals available is always low. Intravascular ultrasound (IVUS) may be useful to guide the subintimal guidewire to re‐enter the true lumen. We evaluated the clinical feasibility and efficacy of the IVUS‐guided wiring re‐entry technique for these complex CTO lesions.

Methods

Twenty consecutive patients (19 male, mean age: 65.3 ± 12.8 years) with both failed antegrade and retrograde approaches were enrolled. The IVUS catheter was introduced into the subintimal space to identify the entry point into the subintimal space, and guide another stiff wire to re‐enter the true lumen with the adjacent side‐branch or first wire as markers, or using IVUS‐guided parallel wire technique.

Results

The entry point into the subintimal space was identified by IVUS in all cases, and the IVUS‐guided wiring re‐entry technique succeeded in 17 cases (85%). No procedure‐related complication was noted except one case of delayed cardiac tamponade due to the wire perforation. During the mean follow‐up period of 1.9 ± 1.3 years, there was no adverse cardiac event, except one patient died of the complication of cardiac transplantation.

Conclusion

The IVUS‐guided wiringre‐entry technique might be feasible and safe for the recanalization of complex CTO lesions.

     

Rotational atherectomy in the subadventitial space to allow safe and successful chronic total occlusion recanalization: Pushing the limit further

Dissection and re‐entry (DR) techniques have played a key role in the increase of success rates of chronic total occlusion (CTO) recanalization. DR usually allows wiring complex occlusions, even in case of important calcification. In extreme cases, such as in balloon failure‐to‐cross, rotational atherectomy (RA) might be decisive. However, according to experts' recommendations, RA should not be performed in dissection planes because of the high risk of perforation and further extending the dissection, so that its use after DR might be limited. Here, we describe a case of successful right coronary artery CTO recanalization in which, after failure of several antegrade and retrograde techniques, RA was safely performed antegradely in the subadventitial space, thus eventually enabling reverse controlled antegrade and retrograde subintimal tracking (CART). Although the feasibility of RA in CTO percutaneous coronary intervention had already been suggested, this case reports on the novel use of RA to allow further manipulation of the subadventitial space (reverse CART) prior to successful recanalization. © 2017 Wiley Periodicals, Inc.     

Fielder XT导丝在功能性慢性完全闭塞病变中的应用

目的:总结Fielder XT导丝在功能性慢性完全闭塞(CTO)病变介入治疗中的使用体会和经验。方法:回顾分析我科2011年1月~2012年10月住院使用过Fielder XT导丝行介入治疗的CTO病变患者的影像资料。根据CTO病变的影像特点将患者分为绝对性CTO病变组和功能性CTO病变组,分别统计上述两组的CTO病变经皮冠状动脉介入治疗(PCI)成功率,统计两组的Fielder XT导丝的CTO病变通过率,并进行比较分析。结果:功能性CTO病变组和绝对性CTO病变组CTO病变的成功率分别为89%、60%(40/45、22/37,P0.01);两组Fielder XT导丝的通过率分别为:71%、24%(32/45、9/37,P0.01)。结论:Fielder XT在功能性CTO病变中有较高的导丝通过率。     

Value of intravascular ultrasound in the management of coronary chronic total occlusions

Failure of guide wire crossing is the commonest reason for failed procedure in chronic total occlusion (CTO) of the coronary arteries. Intravascular ultrasound can be useful in some cases to achieve. Successful guide wire crossing into the distal true lumen of the coronary artery. We describe two cases demonstrating the role of intravascular ultrasound in successful recannalization of the CTO. © 2009 Wiley‐Liss, Inc.     

Crossing the "balloon uncrossable" chronic total occlusion: Tornus to the rescue

A dedicated balloon with a short beveled tip and the ability to rotate it from the proximal hub was successfully used to dilate the origin of a side branch which became totally occluded after deployment of a stent in the main vessel. Although regular low profile balloons are mostly successful in crossing struts of previously deployed stents, this new device has the potential to offer a more predictable and rapid solution in routine practice. © 2010 Wiley‐Liss, Inc.     

Three-year clinical outcomes after coronary stenting of chronic total occlusion using sirolimus-eluting stents: insights from the rapamycin-eluting stent evaluated at Rotterdam cardiology hospital-(RESEARCH) registry.

BACKGROUND: We previously reported that the 1-year survival-free from target lesion revascularization was 97.4% in patients with chronic total occlusion (CTO) treated with sirolimus-eluting stents (SES). There are currently no long-term results of the efficacy of SES in this subset of lesions. We assessed the 3-year clinical outcomes of 147 patients with CTO treated with either SES or bare metal stents (BMS). METHODS AND RESULTS: A total of 147 (BMS = 71, SES = 76) patients were included. Four patients died in the BMS group while five patients died in the SES group, P = 0.8; two myocardial infarctions occurred in both groups, P = 0.9; and target vessel revascularization was performed in nine patients in the BMS and seven in the SES group, P = 0.5. The cumulative event-free survival of MACE was 81.7% in BMS group and 84.2% in SES group, P = 0.7. Two patients of the SES group had a coronary aneurism at 3-year angiographic follow-up. CONCLUSIONS: The use of SES was no longer associated with significantly lower rates of target vessel revascularization and major adverse cardiac events in patients with CTOs after 3 years of follow-up compared with BMSs.     

Ostial right coronary chronic total occlusion: Transesophageal echocardiographic guidance for retrograde aortic re‐entry

As antegrade options are limited, intervention upon the ostial right coronary artery (RCA) chronic total occlusion (CTO) warrants a retrograde approach. Landmarks for an aggressive approach are concerning as passage of stiff guidewires or electrocautery near the RCA ostium may result in wire passage into structures other than the aorta. We report the first use of transesophageal echocardiography (TEE) to assist retrograde passage of a guidewire into the aorta. For the ostial RCA CTO, TEE guidance may be considered to assist retrograde passage of aggressive guidewires into the aorta.     

Impact of complete percutaneous revascularization in elderly patients with chronic total occlusion

Evidence‐based recommendations for clinical practice are intended to help health care providers and patients make decisions, minimize inappropriate practice variation, promote effective resource use, improve clinical outcomes, and direct future research. The Society for Cardiovascular Angiography and Interventions (SCAI) has been engaged in the creation and dissemination of clinical guidance documents since the 1990s. These documents are a cornerstone of the society's education, advocacy, and quality improvement initiatives. The publications committee is charged with oversight of SCAI's clinical documents program and has created this manual of standard operating procedures to ensure consistency, methodological rigor, and transparency in the development and endorsement of the society's documents. The manual is intended for use by the publications committee, document writing groups, external collaborators, SCAI representatives, peer reviewers, and anyone seeking information about the SCAI documents program.     

Intravascular lithotripsy assisted chronic total occlusion revascularization with reverse controlled antegrade retrograde tracking

Advances in percutaneous coronary intervention (PCI) techniques in chronic total occlusion (CTO) procedures have improved the success of this procedure. CTO PCI via the retrograde approach are facilitated most frequently by reverse controlled antegrade/retrograde tracking (R‐CART). This aims to create a communication between the proximal and distal lumens, which may be achieved between intimal and subintimal spaces. In patients with calcified coronary vessels, creating sufficient disruptions to connect these spaces can be challenging. Intravascular lithotripsy (IVL) has become a useful tool to modify intracoronary calcification for stent deployment and expansion. This case demonstrates the utility of IVL in facilitating connection in R‐CART to complete the CTO PCI where heavy calcification was present at the site of chronic occlusion.     

Electrocautery-assisted re-entry to resolve bilateral aorto-ostial chronic total occlusions due to leaflet obstruction following transcatheter aortic valve replacement

Coronary artery obstruction is a rare but life-threatening complication of transcatheter aortic valve replacement (TAVR). While urgent percutaneous coronary intervention has been described in cases of acute occlusion, little is known about the interventional management of obstruction once it has occurred in the chronic setting. We describe a case in which electrocautery-assisted re-entry was successfully utilized to manage the right coronary artery and left main chronic total occlusion due to leaflet-induced coronary artery obstruction after TAVR.     

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.     

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.     

Open Sesame Technique for chronic total occlusion

Angioplasty for chronic total occlusion (CTO) of the coronary artery is still technically challenging. New techniques to improve the success rate are still required. The inability to penetrate guidewires into the CTO lesion through the proximal cap is one of the most difficult situations. When any guidewire cannot penetrate into the CTO lesion, and if the lesion has both a hard proximal cap and a side branch ramifying at the proximal end of the lesion, the insertion of stiff guidewires and/or balloon inflation in the side branch may induce a geometrical shift of the hard plaque. This in turn enables the entry of a guidewire into the CTO lesion. This procedure has been termed the “Open Sesame Technique.” © 2009 Wiley‐Liss, Inc.