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.     

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。     

The trap and occlude technique for retrograde wire externalization during chronic total occlusion revascularization

Different strategies of retrograde approach were introduced in recent years to improve the success rate of percutaneous coronary intervention for coronary chronic total occlusions. The aim of this report is to describe a new technique, called “Trap and Occlude Technique,” for retrograde wire externalization during CTO percutaneous revascularization. This technique may save time and reduce radiation exposure and procedure‐related bleeding.     

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”.     

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.     

老年患者冠状动脉慢性完全闭塞病变正向技术开通的影响因素

目的探讨老年患者冠状动脉慢性完全闭塞(CTO)病变应用正向技术开通成功的相关因素。方法回顾性收集2013年1月至2014年12月在沈阳军区总医院心内科采用正向技术经皮冠状动脉介入(PCI)治疗的老年冠状动脉CTO患者301例。根据手术是否成功将患者分为PCI成功组250例及PCI失败组51例。收集并比较入选患者的基本资料、临床特征及住院期间不良事件发生情况。采用SPSS 21. 0软件进行统计学分析。根据数据类型,组间比较采用独立样本t检验或χ2检验。二元logistic回归分析影响老年冠状动脉CTO病变开通成功的相关因素。结果入选患者手术总体成功率83. 1%(250/301)。2组患者在体质量、体质量指数、收缩压、糖尿病、吸烟、纽约心脏病学会(NYHA)分级、闭塞段扭曲、桥状侧支、闭塞时间分级和CTO靶血管等方面比较,差异有统计学意义(P 0. 05)。成功组和失败组在住院期间死亡率[0. 8%(2/250) vs1. 9%(1/51)]、心力衰竭[4. 4%(11/250) vs 3. 9%(2/51)]、术后出血[3. 2%(8/250) vs 3. 9%(2/51)]、脑卒中[0%(0/250)vs 0%(0/51)]及围手术期心肌梗死[4. 0%(10/250) vs 3. 9%(2/51)]发生率比较,差异无统计学意义(P 0. 05)。二元logistic回归分析显示,女性(OR=5. 608,95%CI 1. 650~19. 069,P=0. 006)、高收缩压(OR=1. 034,95%CI 1. 004~1. 064,P=0. 024)、急性心肌梗死(AMI)史(OR=7. 213,95%CI 1. 070~48. 645,P=0. 042)、靶血管为左前降支(LAD)(OR=2. 943,95%CI 1. 085~7. 984,P=0. 034)及首先选用Fielder XT导丝(OR=2. 570,95%CI 1. 049~6. 296,P=0. 039)是增加正向技术开通老年冠状动脉CTO病变成功率的有利因素;糖尿病(OR=0. 219,95%CI 0. 086~0. 562,P=0. 002)、既往肾功能不全(OR=0. 336,95%CI 0. 117~0. 967,P=0. 043)、NYHA分级较高(OR=0. 238,95%CI 0. 110~0. 515,P=0. 000)、闭塞段扭曲(OR=0. 130,95%CI 0. 017~0. 969,P=0. 047)及桥状侧支(OR=0. 171,95%CI 0. 046~0. 634,P=0. 008)是降低正向导丝开通老年冠状动脉CTO病变成功率的不利因素。结论既往有AMI史、靶血管为LAD的高收缩压老年女性患者首先选用Fielder XT导丝可增大正向技术开通冠状动脉CTO病变的成功率,具有重要的临床参考价值。     

A new understanding of chronic total occlusion from a novel PCI technique that involves a retrograde approach to the right coronary artery via a septal branch and passing of the guidewire to a guiding catheter on the other side of the lesion.

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) by the antegrade approach is sometimes difficult, especially in the right coronary artery (RCA). We performed successful PCls following a retrograde approach via a septal branch in 2 patients with CTO in RCA. The method involves leading the retrograde guidewire outside the body through an opposite guiding catheter after the wire crosses the target lesion. A balloon or stent could then be delivered retrogradely or antegradely. Even a soft retrograde wire always crosses the lesion through the true lumen, as confirmed by IVUS. Selecting a suitable collateral, a straighter rather than a larger one, is crucial. Our results do not support the current concept regarding CTOs. Probably, the distal fibrous cap is soft and the proximal one has a thin point that soft wires, even blunt ones, can penetrate easily. The distal penetration point appears to connect to the proximal uncalcified thin point. Many channels seem to spread out from the proximal side, tree-like, within the lesion. In the retrograde approach, the wire is unlikely to enter these branch channels. The results suggest that PCI by the retrograde approach may be effective for treating CTOs of RCA.     

Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion

Background:

Retrograde approach through the collateral channels has been recently proposed and has the potential to improve the success rate of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions of the coronary arteries.

Methods:

The author performed retrograde approach for CTO lesions in 45 patients from January 2006 to January 2007 at different medical institutions worldwide. The details of the techniques were examined retrospectively.

Results:

The septal branch route was used in 93% of the cases. The author classified the strategies into six types after the successful crossing of a guidewire into the target artery distal to the CTO lesion through the collateral channels. Among them, “Just landmark,” “Controlled antegrade and retrograde subintimal tracking,” and “Proximal true lumen puncture” strategies were used most frequently (32, 27, and 30%, respectively). The retrograde guidewires could be successfully passed distal to the CTO lesion in 37 patients (82%), among them the final PCI success was achieved in 31 patients, yielding the PCI success by pure retrograde approach of 69%. The final success rate among 45 patients including 42 patients with previous failed attempts was 84% (38 patients). There were no serious complications related to the retrograde approach.

Conclusions:

Retrograde approach with different strategies, mainly through septal arteries, can provide a high success rate with PCI, as shown in 83% of patients with previous failed attempts at traditional PCI for CTO lesions, with there being no serious complications. More experience of this technique and its refinement are required for further improvement of PCI techniques for CTO lesions. © 2008 Wiley‐Liss, Inc.     

Modified subintimal transcatheter withdrawal: A novel technique for hematoma decompression to facilitate distal reentry during coronary chronic total occlusion recanalization

A controlled antegrade dissection and reentry technique is the most commonly employed crossing strategy for long coronary chronic total occlusions. The development of compressive hematoma is a recognized complication and results in the impairment of distal vessel visualization and hinders successful reentry attempts. We describe a novel technique utilizing a widely available microcatheter to decompress the subintimal hematoma to restore distal visualization and allow successful reentry.     

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.     

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.     

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.     

Double trapper technique: A novel technique to facilitate retrograde wire externalization in aorto‐ostial chronic total occlusion intervention without using snare

Chronic total occlusion (CTO) remains a technical challenge for the interventional cardiologists. The application of the retrograde approach has dramatically improved success rates of CTO PCI. However, retrograde wire externalization could be very difficult especially when the antegrade guiding catheter cannot sit into the coronary ostium stably. We report a novel technique to facilitate retrograde wire externalization in aorto‐ostial chronic total occlusion intervention without using snare.     

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.     

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.     

“Move the cap” technique for ambiguous or impenetrable proximal cap of coronary total occlusion

Antegrade crossing remains the most commonly employed crossing strategy for coronary chronic total occlusions (CTOs) but can be challenging to perform in cases of ambiguous or impenetrable proximal cap. To successfully treat such cases, we describe a technique named “move the cap,” in which the subintimal space is entered proximal to the proximal cap using a stiff coronary guidewire or facilitated by inflating a slightly oversized balloon. Subintimal guidewire entry is followed by standard antegrade dissection and re‐entry. The “move the cap” technique can facilitate crossing of CTOs with ambiguous or impenetrable cap, while minimizing the risk of perforation. This technique is also useful for treating balloon uncrossable lesions. © 2015 Wiley Periodicals, Inc.