scholarly journals New Aspects in Percutaneous Coronary Intervention of Chronic Total Occlusions

2019 ◽  
Author(s):  
Judit Karácsonyi
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Intervention ◽  
Intravascular Imaging ◽  
Complication Rates ◽  
Technical Failure ◽  
Success Rates ◽  
Chronic Total Occlusions ◽  
Percutaneous Coronary ◽  
Procedural Success ◽  
The Impact

Coronary Chronic total occlusions (CTOs) are defined as coronary lesions with Thrombolysis in Myocardial Infarction (TIMI) grade 0 flow of at least 3-month duration. Symptomatic patients with CTOs can be managed in three ways, conservatively with medical therapy, with coronary artery bypass grafting (CABG) or with percutaneous coronary intervention (PCI). CTO PCI can be challenging to perform with variable success rates, depending on operator experience and expertise, but with the development of new techniques and equipment the success rates are getting higher and the complication rates lower. In this dissertation, we focused on three aspects of CTO PCI: (a) the impact of prior failure on the outcomes of CTO PCI, (b) balloon uncrossable lesions and (c) the frequency of use and outcomes of intravascular imaging. We examined the prevalence, clinical and angiographic characteristics, management and procedural outcomes of CTO PCIs in a contemporary, large, multicenter CTO PCI registry. Prior CTO PCI failure has been associated with lower procedural success rates and is part of the Japanese Chronic Total Occlusion (J-CTO) score that was developed to predict the likelihood of successful guidewire crossing within 30 minutes. We sought to examine the impact of prior failure on the subsequent outcomes CTO PCI. The main finding of our study is that a prior failed CTO PCI attempt is associated with higher angiographic complexity, longer procedural duration and fluoroscopy time, but not with lower success and higher complication rates of subsequent CTO PCI attempts. Balloon uncrossable lesions are lesions that cannot be crossed with a balloon after successful advancement of the guidewire distal to the lesion. These lesions can be challenging to treat, requiring specialized techniques and equipment. In our study, we found that balloon uncrossable CTOs are common, are associated with high rates of technical failure, and require specialized techniques for successful treatment. Intravascular imaging can facilitate CTO PCI. Use of intravascular ultrasound (IVUS) for stent optimization during CTO PCI has been shown to improve long-term outcomes, yet its impact on crossing has received limited study. In our study, we found that intravascular imaging is frequently performed during CTO PCI both for crossing and for stent selection/ optimization. Despite its use in more complex lesion subsets, intravascular imaging was associated with similar rates of technical and procedural success for CTO PCI.

scholarly journals The Impact of Calcium on Chronic Total Occlusion Management

2021 ◽  
Vol 16 ◽  
Author(s):  
Claudia Cosgrove ◽  
Kalaivani Mahadevan ◽  
James C Spratt ◽  
Margaret McEntegart
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Success Rates ◽  
Total Occlusion ◽  
Chronic Total Occlusions ◽  
Percutaneous Coronary ◽  
Procedural Success ◽  
The Impact

Coronary artery calcification is prevalent in chronic total occlusions (CTO), particularly in those of longer duration and post-coronary artery bypass. The presence of calcium predicts lower procedural success rates and a higher risk of complications of CTO percutaneous coronary intervention. Adjunctive imaging, including pre-procedural computed tomography and intracoronary imaging, are useful to understand the distribution and morphology of the calcium. Specialised guidewires and microcatheters, as well as penetration, subintimal entry and luminal re-entry techniques, are required to cross calcific CTOs. The use of both atherectomy devices and balloon-based calcium modification tools has been reported during CTO percutaneous coronary intervention, although they are limited by concerns regarding safety and efficacy in the subintimal space.

scholarly journals Advances in percutaneous coronary intervention for chronic total occlusions: current antegrade dissection and reentry techniques and updated algorithm

2020 ◽  
Vol 29 (1) ◽  
pp. 52-59 ◽  
Author(s):  
T. Berkhout ◽  
B. E. Claessen ◽  
M. T. Dirksen
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Hybrid Algorithm ◽  
Coronary Intervention ◽  
Complication Rates ◽  
Success Rates ◽  
New Materials ◽  
True Lumen ◽  
Chronic Total Occlusions ◽  
Percutaneous Coronary

AbstractPercutaneous coronary intervention (PCI) for chronic total occlusions (CTO) is considered relatively complex with low success rates and high complication rates. Treating a CTO with PCI using the hybrid algorithm increases success rates with acceptable complication rates. An essential part of the hybrid algorithm is antegrade dissection and reentry (ADR). In PCI of a non-CTO coronary lesion, the guidewire over which the stent is advanced and placed stays within the true lumen of the coronary artery. ADR techniques make it possible to cross the lesion through the wall of the coronary artery, the subintimal space, thus creating a small bypass within the architecture of the coronary artery and restoring antegrade blood flow. ADR increases success rates, especially in more difficult CTO procedures. In the last decade, new materials and techniques have been introduced in quick succession, which are summarised in this review. Consequently an updated ADR algorithm is presented, which can support the CTO operator during an ADR procedure.

scholarly journals Contemporary Strategies and Outcomes of Dedicated Chronic Total Occlusion Percutaneous Coronary Intervention Programs: A Prospective Multicentre Registry

2021 ◽  
Vol 2021 ◽  
pp. 1-7
Author(s):  
Maarten Vanhaverbeke ◽  
Ward Eertmans ◽  
Wouter Holvoet ◽  
Ief Hendrickx ◽  
Keir McCutcheon ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Temporal Trends ◽  
Coronary Intervention ◽  
P Value ◽  
Complication Rates ◽  
Success Rates ◽  
Technical Success ◽  
Total Occlusion ◽  
Chronic Total Occlusions ◽  
Percutaneous Coronary

Background. The field of CTO PCI is expanding, but successful and safe percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTO) requires a substantial resource and experience investment. We aimed to assess temporal trends in strategies and outcomes of 2 dedicated programs for CTO PCI. Methods. Between 2011 and 2020, 920 CTO PCI procedures were prospectively included at 2 referral centres in Belgium. Temporal trends were assessed, and logistic regression models were built to identify predictors of outcome. Results. Despite an increase in lesion complexity (the J-CTO score increased from 1.3 in year 1 to 1.7–2.0 in years 8-9, p < 0.001 ), technical success improved from 70.0% to 85.6% in year 9 (p value for trend <0.001). We observed the most significant improvement starting at years 3-4 (OR 2.3 in year 4 versus year 1, p = 0.018 ). Together with an increase in success rates and lesions complexity, there was an increase in the use of dual injections, retrograde approaches, the number of balloons and stents, and the use of microcatheters. Conversely, there was a decrease in large bore access, an increase in radial approach, and a shift towards contemporary dissection/reentry techniques. This strategy resulted in a stable major complication rate of 4.7% (p value for trend 0.33). The rate of coronary procedure-related myocardial injury was high (71.0%) and was associated with the use of more intracoronary devices. Conclusions. Three to four years after initiation of a dedicated CTO PCI program with 50 CTO PCIs per year, consistent high technical success and low complication rates are achieved using contemporary strategies.

280The impact of epicardial collateral use on the outcomes of retrograde chronic total occlusion percutaneous coronary intervention

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Karacsonyi ◽  
D Karmpaliotis ◽  
K Alaswad ◽  
F A Jaffer ◽  
R W Yeh ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Complication Rates ◽  
Success Rates ◽  
Bypass Grafts ◽  
Collateral Vessel ◽  
Total Occlusion ◽  
Percutaneous Coronary ◽  
The Impact

Abstract Background The impact of the type of collateral vessel used on the outcomes of retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods We reviewed the baseline clinical and angiographic characteristics and procedural outcomes of 1,501 retrograde CTO PCIs performed in 1494 patients between 2012 and 2019 at 26 centres. Purpose We sought to examine the impact of the type of collateral vessel used on the outcomes of retrograde CTO PCI. Results Mean patient age was 65.0±10 years and 86% were men. Septal collaterals or bypass grafts were used in 66%, epicardial collaterals in 34% of lesions. Compared with cases in which only septal collaterals and bypass grafts were used, use of epicardial collaterals were associated with larger vessel diameter (3.0 [2.5; 3.0] vs. 3.0 [2.5, 3.2] mm, p=0.005), more moderate/severe tortuosity (55% vs. 42%, p<0.0001), more moderate/severe calcification (73% vs. 65%, p=0.002), and higher Japan chronic total occlusion score (3.34±1.02 vs. 3.11±1.07, p<0.0001). Epicardial collateral use was associated with lower technical (76.3% vs. 80.6%, p=0.053) and procedural (71.9% vs. 77.8%, p=0.011) success rates, but similar incidence of major cardiac adverse events (4.72% vs. 4.56%, p=0.889). Epicardial collaterals were associated with more perforations (10.63% vs. 7.30%, p=0.028). Epicardial collateral use was associated with longer fluoroscopy time (82 [64, 104] 76 [(55, 102] p=0.0003) and higher contrast volume (300 [221; 414] ml vs. 270 [200; 370] ml, p<0.0001). Conclusion In a contemporary, multicenter registry epicardial collaterals were used in approximately one-third of retrograde CTO PCIs. Use of epicardial collaterals was associated with lower success but similar major complication rates. Acknowledgement/Funding Minneapolis Heart Institute Foundation

The impact of gender on outcomes in patients with chronic total coronary occlusions undergoing percutaneous coronary intervention: results from a Dutch nationwide registry including 7560 patients

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Van Veelen ◽  
J Elias ◽  
I.M Van Dongen ◽  
J.P.S Henriques ◽  
P Knaapen
Keyword(s):  
Cardiovascular Disease ◽  
Percutaneous Coronary Intervention ◽  
Survival Curve ◽  
Coronary Intervention ◽  
Chronic Total Occlusions ◽  
Nationwide Registry ◽  
Percutaneous Coronary ◽  
Baseline Characteristics ◽  
Gender Based ◽  
The Impact

Abstract Background Females comprise a minority of patients with chronic total occlusions (CTO). It is known that men have a greater benefit from CTO percutaneous coronary intervention (PCI) than women. We aimed to determine gender-based differences in baseline characteristics and outcomes after PCI in patients with CTO. Methods The Netherlands Heart Registration (NHR) is a nationwide registry that registers outcomes of cardiac interventions. For the purpose of this analysis, the data of all patients undergoing PCI from inception of the NHR to December 2018 were selected, that included PCI with at least one CTO in one of the treated coronary arteries. We compared baseline characteristics and the outcomes 1 year mortality, 30 day myocardial infarction (MI) and target vessel revascularization (TVR) &lt;1 year between men and women. Results A total of 7560 patients were identified that underwent PCI between January 1, 2015 and December 31, 2018 with at least 1 CTO in the treated vessel. A total of 5850 was male (77.4%) and 1710 was female (22.6%). Women were older (68.5±10.6 versus 64.7±10.6 years old, p&lt;0.001), and more frequently had diabetes (29.4% [n=529] versus 25.0% [n=1602], p&lt;0.001) and kidney disease (4.5% [n=529] versus 2.2% [n=142], p&lt;0.001). However, men had more extensive cardiovascular disease, i.e. multi-vessel disease (56.0% [n=3584] versus 50.4% [n=912], p&lt;0.001), previous MI (39.7% [n=2527] versus 31.0% [n=555], p&lt;0.001), previous PCI (48.2% [n=1967] versus 40.2% [n=455], p&lt;0.001) and previous coronary artery bypass grafting (16.8% [n=1085] versus 10.5% [n=191], p&lt;0.001) and more frequently presented with an out-of-hospital cardiac arrest, compared to women (2.1% [n=136] versus 1.1% [n=20], p=0.004). The 1-year mortality was higher in women (10.3% versus 7.5%, p&lt;0.001), as well as the 30-day MI (0.9% versus 0.4%, p=0.043), but men had higher risk for TVR&lt;1 year (11.7% versus 9.5%, p=0.044). Corrected for age and comorbidities, female gender was an independent predictor for mortality (Figure 1; odds ratio 1.83, 95% confidence interval 1.08–3.11, p=0.025). Conclusion In this nationwide registry comprising 7560 CTO patients undergoing PCI, significant gender-based differences were found. Males were found to have more extensive cardiovascular disease. However, females were at higher risk of mortality, possibly due to higher age and higher prevalence of concomitant comorbidities. Figure 1. Survival curve Funding Acknowledgement Type of funding source: None

Chronic total occlusions

2018 ◽  
pp. 315-336
Author(s):  
Colm G. Hanratty ◽  
James C. Spratt ◽  
Simon J. Walsh
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Clinical Indication ◽  
Success Rates ◽  
Total Occlusion ◽  
Chronic Total Occlusions ◽  
Percutaneous Coronary ◽  
Set Up

Chronic total occlusion (CTO) of a coronary artery remains one of the most challenging scenarios in cinical practice. There is much debate about whether opening a CTO is clinically indicated and the procedures are often considered too risky. As a result many patients with a clinical indication for percutaneous coronary intervention (the presence of angina despite medical therapy, with proven ischaemia and viability) are not offered treatment. This chapter will aim to demystify the procedure by explaining how pathophysiological features can help understand the anatomy and how cath lab set-up can increase procedural efficiency, safety, and overall success rates. There are four methods by which a CTO can be opened and we will describe these methods and the anatomically salient features to help select the most appropriate method with which to start.

scholarly journals Overview of Technical and Cost Considerations in Complex Percutaneous Coronary Intervention

2011 ◽  
Vol 9 (1) ◽  
pp. 17 ◽  
Author(s):  
J Raider Estrada ◽  
Jonathan D Paul ◽  
Atman P Shah ◽  
Sandeep Nathan ◽  
◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Saphenous Vein Graft ◽  
Significant Proportion ◽  
Coronary Intervention ◽  
Cardiac Events ◽  
Chronic Total Occlusions ◽  
Percutaneous Coronary ◽  
Complex Percutaneous Coronary Intervention ◽  
Artery Disease ◽  
Procedural Success

Complex percutaneous coronary intervention (PCI), encompassing an ever-expanding range of challenging lesion sets and patient populations, accounts for a significant proportion of PCI procedures being performed currently. Specific lesion types associated with lower rates of procedural success and higher rates of recurrence or major adverse cardiac events (MACE) include multivessel disease, unprotected left main coronary artery disease, fibrocalcific or undilatable lesions, chronic total occlusions, degenerated saphenous vein graft lesions, thrombotic lesions, and bifurcation disease. Validated tools and technical strategies currently exist to address most procedural scenarios encountered and should be familiar to the complex PCI operator. Anticipated clinical outcomes, projected resource utilization, and cost considerations should all factor into the decisions of when, how, and in whom to intervene.

The Role of Percutaneous Coronary Intervention in the Treatment of Chronic Total Occlusions: Rationale and Review of the Literature

2019 ◽  
Vol 17 (3) ◽  
pp. 278-290
Author(s):  
Harsh Agrawal ◽  
Richard A. Lange ◽  
Ruben Montanez ◽  
Soma Wali ◽  
Khan Omar Mohammad ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Coronary Intervention ◽  
Cochrane Library ◽  
Success Rates ◽  
Chronic Total Occlusions ◽  
Percutaneous Coronary

Background: Chronic total occlusion (CTO) of a coronary artery is defined as an occluded segment with no antegrade flow and a known or estimated duration of at least 12 weeks. </P><P> Objective: We considered the current literature describing the indications and clinical outcomes for denovo CTO- percutaneous coronary intervention (PCI), and discuss the role of CTO-PCI and future directions for this procedure. </P><P> Methods: Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL were searched and relevant studies of CTO-PCI were selected for review. </P><P> Results: The prevalence of coronary artery CTO’s has been reported to be ~ 20% among patients undergoing diagnostic coronary angiography for suspected coronary artery disease. Revascularization of any CTO can be technically challenging and a time-consuming procedure with relatively low success rates and may be associated with a higher incidence of complications, particularly at non-specialized centers. However, with an increase in experience and technological advances, several centers are now reporting success rates above 80% for these lesions. There is marked variability among studies in reporting outcomes for CTO-PCI with some reporting potential mortality benefit, better quality of life and improved cardiac function parameters. Anecdotally, properly selected patients who undergo a successful CTO-PCI most often have profound relief of ischemic symptoms. Intuitively, it makes sense to revascularize an occluded coronary artery with the goal of improving cardiovascular function and patient quality of life. </P><P> Conclusion: CTO-PCI is a rapidly expanding specialized procedure in interventional cardiology and is reasonable or indicated if the occluded vessel is responsible for symptoms or in selected patients with silent ischemia in whom there is a large amount of myocardium at risk and PCI is likely to be successful.

Sign in / Sign up

Export Citation Format

Share Document