Perforation of the atretic pulmonary valve using chronic total occlusion (CTO) wire and coronary microcatheter

Background and objective: Chronic total occlusion (CTO) guidewire have been recently reported as an alternative to radiofrequency for perforating atretic pulmonary valve. Since procedure failures or perforation of the right ventricle still occurred with CTO, we tried to enhance the stability, steering, and pushability of the wire using a microcatheter in order to improve the safety and efficacy of the procedure.
Methods: We performed pulmonary valve perforation with CTO guidewire and microcatheter in five consecutive newborns with pulmonary atresia with intact ventricular septum (PA‐IVS) under fluoroscopic and echocardiographic control.
Results: The valve was easily perforated at the first attempt for all patients. After perforation, the microcatheter positioned in the main pulmonary artery allowed the exchange of the CTO guidewire for a more flexible wire, avoiding lesion and facilitating manipulation in the distal pulmonary branch arteries. The pulmonary valve was then dilated with balloons of increasing size as usually performed. We did not experience any procedural or early complications. Blalock‐Taussig shunt was performed in 2 children because of a persistent cyanosis, 4 and 10 days after perforation.
Conclusion: The combined use of a CTO guide and a microcatheter appears to be a safe and reliable technique for perforating the pulmonary valve of newborns with PA‐IVS. Further procedures with this approach are needed to confirm this first experience.     

The impact of percutaneous coronary intervention of chronic total occlusions on left ventricular function and clinical outcomes

A meta-analysis by Hoebers et al. reported that successful chronic total occlusion (CTO) recanalization resulted in an increase in left ventricular (LV) ejection fraction by 4.44% (P<0.01) and a reduction in LV end-diastolic volume by 6.14 mL/m² during follow-up as compared with baseline, suggesting beneficial LV remodeling. These findings are important as the myocardium supplied by a CTO frequently has sustained irreversible injury and further support the clinical benefits of CTO interventions.     

Effect of revascularization on coronary chronic total occlusion in patients undergoing coronary artery bypass grafting

BackgroundBypass grafting for chronic total occlusions (CTOs) remains surgically challenging and controversial. Therefore, we evaluated the incidence and clinical outcomes of revascularization on CTOs undergoing coronary artery bypass grafting (CABG).MethodsAmong 828 patients who underwent isolated CABG from January 2010 to December 2018, 245 patients (29.6%) diagnosed with at least one CTO were included and retrospectively reviewed. Primary endpoints were 30-day and overall mortality. Secondary endpoint was the composite outcome of major adverse cardiac and cerebrovascular events (MACCE).ResultsWith a mean follow-up of 56.6±6.5 months in 245 patients with CTOs, 51 patients (20.8%) received incomplete revascularization (ICR) for CTO lesions. Risk factor analysis showed that ICR was associated with increased 30-day [odds ratio 8.62; 95% confidence interval (CI): 1.64–50; P=0.011] and overall mortality (hazard ratio (HR) 2.13; 95% CI: 1.07–4.21; P=0.03). ICR also increased the risk of MACCE (HR 1.98; 95% CI: 1.12–3.54; P=0.01). Freedom from overall mortality was 92.8%, 90.4%, and 86.8% in the complete revascularization group, and 86.3%, 80.0%, and 72.7% in the ICR group, at 1, 3, and 5 years, respectively (P=0.004).ConclusionsIn patients with CTOs undergoing CABG, the rate of ICR was 20.8%, and it significantly increased the risk of mortality and MACCE. Further studies in a large cohort are needed.     

Update in the Percutaneous Management of Coronary Chronic Total Occlusions

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been rapidly evolving during recent years. With improvement in equipment and techniques, high success rates can be achieved at experienced centers, although overall success rates remain low. Prospective, randomized-controlled data regarding optimal use and indications for CTO PCI remain limited. CTO PCI should be performed when the anticipated benefit exceeds the potential risk. New high-quality studies of the clinical outcomes and techniques of CTO PCI are needed, as is the expansion of expert centers and operators that can achieve excellent clinical outcomes in this challenging patient and lesion subgroup. In the current review the authors summarize the latest publications in CTO PCI and provide an overview of the current state of the field.     

Technique and Clinical Outcomes of Combined Stent Placement for Postthrombotic Chronic Total Occlusions of the Iliofemoral Veins

Purpose

To evaluate the technical aspects and early clinical results of combined stent placement for the management of postthrombotic syndrome (PTS) in chronic total occlusions (CTOs) of the iliofemoral veins.

Influence of collaterals on the left ventricular end-diastolic pressure and serum NT-proBNP levels in patients with coronary chronic total occlusion

Objective

Although numerous studies have shown the protective effects of the well-developed coronary collaterals on left ventricular functions, the relationship between collateral grade and left ventricular end diastolic pressure has not been studied in chronic total occlusion patients. Also, there are conflicting data on the effect of collaterals on NT-proBNP levels. The aim of our study was to evaluate the relationship between coronary collateral circulation and left ventricular end diastolic pressure and NT-proBNP levels in chronic total occlusion patients.

Chronic Total Occlusion of the Iliac Artery: Endoluminal Reentry Using a Metal Stiffening Cannula

When chronic total occlusion of the iliac artery cannot be crossed with traditional guide wires and catheters, the metal stiffener from a universal drainage catheter kit can be shaped and used to direct a guide wire from a subintimal tract into the true lumen. In the present report, reentry was achieved in 12 of 12 patients with the use of the cannula. This technique provides a useful alternative for treatment of chronic total iliac occlusions.