scholarly journals Application of the gunsight technique to facilitate subintimal arterial flossing with antegrade-retrograde intervention for the treatment of lower extremity chronic total occlusion

2020 ◽  
Vol 4 ◽  
pp. 12
Author(s):  
Daniel Rohan Phadke ◽  
Daniel Sheeran ◽  
John Angle ◽  
Luke Wilkins
Keyword(s):  
Clinical Outcome ◽  
Lower Extremity ◽  
Endovascular Treatment ◽  
Chronic Total Occlusion ◽  
Technical Success ◽  
Total Occlusion ◽  
Chronic Total Occlusions ◽  
Percutaneous Puncture ◽  
Novel Technique ◽  
Is Failure

Objectives: Endovascular treatment of atheromatous chronic total occlusions (CTOs) of the lower extremity using the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) method may fail due to inability to position the antegrade and retrograde wires in the same plane. Failed attempted SAFARI in three limbs, in two patients, was rescued using a gunsight technique. Material and Methods: Retrospective procedure database review revealed three procedures where an occlusion could not be crossed despite antegrade and retrograde access which were treated using a novel technique for percutaneous puncture through antegrade and retrograde loop snares (gunsight technique). Results: Three limbs in two patients (mean age: 64 years) were treated using the gunsight technique. All three CTOs were successfully crossed and dilated with angioplasty and/or stents. A positive clinical outcome was achieved in each of the three affected limbs. Conclusion: The gunsight technique can improve technical success of SAFARI in the treatment of CTOs for atheroocclusive disease when there is failure to cross the lesion with standard endoluminal or subintimal approaches.

scholarly journals Tibiopedal and distal femoral retrograde vascular access for challenging chronic total occlusions: predictors for technical success, and complication rates in a large single-center cohort

2020 ◽  
Vol 31 (1) ◽  
pp. 535-542
Author(s):  
Gerd Grözinger ◽  
Jan Hallecker ◽  
Ulrich Grosse ◽  
Roland Syha ◽  
Dominik Ketelsen ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Success Rate ◽  
Vascular Access ◽  
Chronic Total Occlusion ◽  
Lesion Length ◽  
Complication Rates ◽  
Technical Success ◽  
Total Occlusion ◽  
Femoral Access ◽  
Technical Success Rate

Abstract Objective To evaluate the safety and effectiveness of tibiopedal and distal femoral access for retrograde crossing of chronic total occlusion (CTO) in Rutherford stage III to VI peripheral arterial occlusive disease, and to determine factors that correlate with technical success. Material and methods One hundred seventy-one consecutive patients were included in this retrospective study. Rutherford stages were III, IV, and V/VI in 24%, 8%, and 67% of patients. Inclusion criteria were CTO at the superficial femoral (SFA), popliteal (PA), and/or below-the-knee (BTK) level, and a failed antegrade treatment followed by a distal retrograde approach. The numbers of occluded vascular levels (OVL), lesion length, degree of calcification, technical success rate, complications, and clinical outcome were noted. Results OVL were 1 in 72%, 2 in 20%, and 3 in 8% of patients. CTOs were longer than 20 cm in 45.6% of cases and showed severe calcifications in 50.3%. Target vessels for distal access were the distal SFA/PA in 17% and BTK in 83%. The overall technical success rate was 82%. Severe calcification decreased technical success (p = 0.01) despite lesion length and Rutherford stage. Clinical outcome improved in 123/152 patients with a significant increase of the median ABI (N = 158) from 0.53 (interquartile range 0.39 to 0.61) to 0.85 (0.59 to 1.03; p < 0.001). Complications were reported in 7.6% cases with 2.3% related to the distal vascular access. Conclusion The tibiopedal and distal femoral retrograde access presents a safe and effective treatment option of CTOs at the thigh and/or BTK after a failed antegrade attempt improving clinical outcome. Technical success decreased with lesion’s degree of calcification. Key Points • Safety and effectiveness of the tibiopedal and distal femoral access for retrograde crossing of chronic total occlusion. • Target lesion’s degree of calcification decreases technical success. • Complications related to the distal vascular access were rare.

scholarly journals Percutaneous Coronary Intervention to Treat Chronic Total Occlusion: Predictors of Technical Success and One-Year Clinical Outcome

2014 ◽  
Vol 41 (1) ◽  
pp. 40-47 ◽  
Author(s):  
Mojtaba Salarifar ◽  
Mohammad-Reza Mousavi ◽  
Sepideh Saroukhani ◽  
Ebrahim Nematipour ◽  
Seyed Ebrahim Kassaian ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Clinical Outcome ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Technical Failure ◽  
Technical Success ◽  
Total Occlusion ◽  
Percutaneous Coronary ◽  
Procedural Success ◽  
One Year

We investigated the overall success rate of percutaneous coronary intervention (PCI) as a treatment for coronary chronic total occlusion and sought to determine the predictive factors of technical success and of one-year major adverse cardiac events (MACE). These factors have not been conclusively defined. Using data from our single-center PCI registry, we enrolled 269 consecutive patients (mean age, 56.13 ± 10.72 yr; 66.2% men) who underwent first-time PCI for chronic total occlusion (duration, ≥3 mo) from March 2006 through September 2010. We divided them into 2 groups: procedural success and procedural failure. We compared occurrences of in-hospital sequelae and one-year MACE between the groups, using multivariate models to determine predictors of technical failure and one-year clinical outcome. Successful revascularization was achieved in 221 patients (82.2%). One-year MACE occurred in 13 patients (4.8%), with a predominance of target-vessel revascularization (3.7%). The prevalence of MACE was significantly lower in the procedural-success group (1.8% vs 18.8%; P &lt;0.001). In the multivariate model, technical failure was the only predictor of one-year MACE. The predictors of failed procedures were lesion location, multivessel disease, the occurrence of dissection, a Thrombolysis In Myocardial Infarction flow grade of 0 before PCI, the absence of tapered-stump arterial structure, and an increase in serum creatinine level or lesion length. In our retrospective, observational study, PCI was successful in a high percentage of chronic total occlusion patients and had a low prevalence of complications. This suggests its safety and effectiveness as a therapeutic option.

scholarly journals A New Algorithm for Crossing Chronic Total Occlusions From the Asia Pacific Chronic Total Occlusion Club

2017 ◽  
Vol 10 (21) ◽  
pp. 2135-2143 ◽  
Author(s):  
Scott A. Harding ◽  
Eugene B. Wu ◽  
Sidney Lo ◽  
Soo Teik Lim ◽  
Lei Ge ◽  
...  
Keyword(s):  
Chronic Total Occlusion ◽  
Asia Pacific ◽  
Total Occlusion ◽  
Chronic Total Occlusions

scholarly journals Antegrade Chronic Total Occlusion Strategies: A Technical Focus for 2020

2020 ◽  
Vol 15 ◽  
Author(s):  
Calum Creaney ◽  
Simon J Walsh
Keyword(s):  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Total Occlusion ◽  
Chronic Total Occlusions ◽  
Initial Strategy ◽  
Percutaneous Coronary ◽  
Probability Of Success ◽  
Procedural Strategy ◽  
Low Probability ◽  
Procedural Success

Chronic total occlusions (CTOs) are common in patients with ischaemic heart disease. In many countries, patients with CTOs are underserved by percutaneous coronary intervention (PCI). One of the barriers to CTO PCI is the technical challenges of these procedures. Improvements in technique and dedicated devices for CTO PCI, combined with advances in procedural strategy, have resulted in a dramatic increase in procedural success and outcomes. Antegrade wiring (AW) is the preferred initial strategy in short CTOs, where the proximal cap and course of the vessel is understood. For many longer, more complex occlusions, AW has a low probability of success. Dissection and re-entry techniques allow longer CTOs and those with ambiguous anatomy to be crossed safely and efficiently, and CTO operators must also be familiar with these strategies. The CrossBoss and Stingray system is currently the primary targeted re-entry device used during antegrade dissection and re-entry (ADR), and there continues to be an evolution in its use to increase procedural efficiency. In contrast to older ADR techniques, targeted re-entry allows preservation of important side-branches, and there is no difference in outcomes compared to intraplaque stenting.

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 Development and first results of a dedicated chronic total occlusion programme

2019 ◽  
Vol 29 (1) ◽  
pp. 14-21 ◽  
Author(s):  
H. W. van der Werf ◽  
P. J. Vlaar ◽  
P. van der Harst ◽  
E. Lipšic
Keyword(s):  
Chronic Total Occlusion ◽  
High Volume ◽  
Coronary Intervention ◽  
Technical Success ◽  
Total Occlusion ◽  
Technical Success Rate ◽  
Increased Risk ◽  
Percutaneous Coronary ◽  
First Results ◽  
Hospital Deaths

Abstract Objective To describe the development and first results of a dedicated chronic total occlusion (CTO) programme in a tertiary medical centre. Background Because of the complexity and the increased risk of complications during percutaneous coronary intervention (PCI) for CTO, it is essential that less experienced and evolving CTO centres perform regular quality analyses. Methods We therefore performed analyses to describe the results during the first 3 years of a dedicated CTO programme at a high-volume PCI centre. In addition, we discuss the strategies employed to develop such a programme. Results A total of 179 consecutive patients undergoing 187 CTO procedures were included in the study. The complexity of the CTO lesions increased from a mean J‑CTO (Japanese Multicentre CTO Registry) score of 1.3 in 2015 to 2.1 in 2017. In the majority of cases, the antegrade wire escalation technique was performed. Final technical success rate was 78.5% in 175 patients with a single CTO and 80.2% of all 187 CTO procedures. No peri-procedural or in-hospital deaths occurred. One peri-procedural myocardial infarction occurred. Cardiac tamponade occurred in 2 cases, both managed by pericardiocentesis. No urgent cardiac surgery was necessary. Survival and revascularisation rates at 30 days and 1 year were excellent. Conclusion Following initiation of a dedicated CTO programme, using up-to-date techniques and strategies, procedural and clinical outcome were comparable with current standards in established centres.

Extravascular Recanalization of Chronic Total Occlusions

2018 ◽  
Author(s):  
S. Lowell Kahn
Keyword(s):  
Lower Extremity ◽  
Success Rate ◽  
Technical Failure ◽  
Technical Success ◽  
Contrast Injection ◽  
True Lumen ◽  
Chronic Total Occlusions ◽  
Technical Success Rate ◽  
The Wire

Subintimal revascularization is a mainstay of therapy for lower extremity interventions. This stems from the realization that true lumen traversal is not always possible, subintimal revascularization has a high technical success rate, and the subintimal space may confer advantages over a heavily calcified true lumen. Most commonly in the tibial vasculature, there are times when subintimal recanalization is not possible because the wire and catheter may leave the subintimal plane and enter the periadventitial tissue. Although this is not intentional, exit from the vessel historically results in a technical failure because future passes of the wire and catheter are likely to follow suit, as evidenced by extravasation on contrast injection. This chapter describes two techniques to salvage this scenario and accept an extravascular tract for revascularization: the Outback® extravascular revascularization technique and the percutaneous gun-sight extravascular revascularization technique.

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