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Safety is of critical importance to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). This global consensus statement provides guidance on how to optimise the safety of CTO) PCI, addressing the following 12 areas: 1. Set-up for safe CTO PCI; 2. Guide catheter--associated vessel injuries; 3. Hydraulic dissection, extraplaque haematoma expansion, and aortic dissections; 4. Haemodynamic collapse during CTO PCI; 5. Side branch occlusion; 6. Perforations; 7. Equipment entrapment; 8. Vascular access considerations; 9. Contrast-induced acute kidney injury; 10. Radiation injury; 11 When to stop; and, 12. Proctorship. This statement complements the global CTO crossing algorithm; by advising how to prevent and deal with complications, this statement aims to facilitate clinical practice, research, and education relating to CTO PCI.
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Consenso , Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Enfermedad Crónica , Oclusión Coronaria/cirugía , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/normas , Guías de Práctica Clínica como AsuntoRESUMEN
Although outcomes have improved with new-generation drug-eluting stents, few reports have analyzed the risk factors associated with chronic outcomes of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). This study aimed to investigate the independent risk factors for target lesion revascularization (TLR) and major adverse cardiac and cerebrovascular events (MACCEs) after CTO-PCI using Japanese multicenter data. A total of 3,666 patients, who underwent CTO-PCI and completed a 1-year follow-up, registered at the Japanese CTO-PCI Expert Registry from 2014 to 2019, were examined. The primary outcome was defined as TLR, and the secondary outcome was MACCEs at the 1-year follow-up. TLRs and MACCEs occurred in 175 (4.8%) and 524 (14.3%) patients, respectively. Multivariate logistic regression analysis demonstrated that in-stent occlusion (ISO) (odds ratio [OR] 2.604, 95% confidence interval [CI] 1.695 to 4.001), hemodialysis (OR 1.784, 95% CI 1.062 to 2.997), diabetes mellitus with insulin use (OR 1.741, 95% CI 1.060 to 2.861), moderate-to-severe calcification (OR 1.726, 95% CI 1.197 to 2.487), and the right coronary artery as the target vessel (OR 1.468, 95% CI 1.018 to 2.117) were significantly associated with TLR. Hemodialysis (OR 2.214, 95% CI 1.574 to 3.113), ISO (OR 1.499, 95% CI 1.127 to 1.993), arteriosclerosis obliterans (OR 1.414, 95% CI 1.074 to 1.863), and multivessel disease (OR 1.356, 95% CI 1.117 to 1.647) were significantly associated with MACCEs. One-year outcomes of new-generation drug-eluting stents for CTO-PCI were favorable, and ISO as a lesion factor and hemodialysis as a patient factor were strongly associated with TLR and MACCEs, respectively.
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Oclusión Coronaria , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Sistema de Registros , Humanos , Intervención Coronaria Percutánea/métodos , Oclusión Coronaria/cirugía , Masculino , Femenino , Japón/epidemiología , Anciano , Enfermedad Crónica , Persona de Mediana Edad , Factores de Riesgo , Resultado del Tratamiento , Estudios de Seguimiento , Complicaciones Posoperatorias/epidemiología , Pueblos del Este de AsiaRESUMEN
Background: The authors devised the tip detection (TD) method and developed AnteOwl WR intravascular ultrasound to standardize intravascular ultrasound-based 3-dimensional wiring for intraplaque tracking in chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). The TD method also allowed antegrade dissection and re-entry (ADR). Combining TD-ADR with Conquest Pro 12 Sharpened Tip (CP12ST) wire, a new ADR wire with the strongest penetration force developed to date, enabled re-entry anywhere except calcification sites. Objectives: This study investigated the efficacy and feasibility of TD-ADR by comparison of procedural outcomes with Stingray-ADR in CTO-PCI. Methods: Twenty-seven consecutive CTO cases treated by TD-ADR with CP12ST wire between August 2021 and April 2023 and 27 consecutive CTO cases treated by Stingray-ADR with Conquest 8-20 (CP20) wire between March 2018 and July 2021 were retrospectively enrolled as the TD-ADR by CP12ST wire group and Stingray-ADR by CP20 wire group, respectively, from 4 facilities that could share technical information on these procedures. Results: The success rate of the ADR procedure was significantly improved (27 of 27 cases [100%] vs 18 of 27 cases [67%], respectively; P = 0.002) and total procedural time was significantly reduced (median procedural time: 145.0 [Q1-Q3: 118.0-240.0] minutes vs 185.0 [Q1-Q3: 159.5-248.0] minutes, respectively; P = 0.028) in the TD-ADR by CP12ST wire group compared to the Stingray-ADR by CP20 wire group. There were few in-hospital major adverse cardiac and cerebrovascular events or no complications in either group. Conclusions: TD-ADR by CP12ST wire can standardize highly accurate ADR in CTO-PCI.
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BACKGROUND: Despite the effectiveness of the retrograde approach for chronic total occlusion (CTO) lesions, there are no standardized tools to predict the success of retrograde percutaneous coronary intervention (PCI). OBJECTIVES: The aim of this study was to develop a prediction tool to identify CTO lesions that will achieve successful retrograde PCI. METHODS: This study evaluated data from 2,374 patients who underwent primary retrograde CTO-PCI and were enrolled in the Japanese CTO-PCI Expert Registry between January 2016 and December 2022 (NCT01889459). All observations were randomly assigned to the derivation and validation cohorts at a 2:1 ratio. The prediction score for guidewire failure in retrograde CTO-PCI was determined by assigning 1 point for each factor and summing all accrued points. RESULTS: The JR-CTO score (moderate-severe calcification, tortuosity, Werner collateral connection grade ≤1, and nonseptal collateral channel) demonstrated a C-statistic for guidewire failure of 0.72 (95% CI: 0.67-0.76) and 0.71 (95% CI: 0.64-0.77) in the derivation and validation cohorts, respectively. Patients with lower scores had higher guidewire and technical success rates and decreased guidewire crossing time and procedural time (P < 0.01). CONCLUSIONS: The JR-CTO (Japanese Retrograde Chronic Total Occlusion) score, a simple 4-item score that predicts successful guidewire crossing in patients undergoing retrograde CTO-PCI, has the potential to support clinical decision-making for the retrograde approach.
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Oclusión Coronaria , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Sistema de Registros , Humanos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Masculino , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Japón , Femenino , Anciano , Enfermedad Crónica , Persona de Mediana Edad , Resultado del Tratamiento , Factores de Riesgo , Reproducibilidad de los Resultados , Técnicas de Apoyo para la Decisión , Medición de Riesgo , Circulación Coronaria , Circulación Colateral , Toma de Decisiones Clínicas , Factores de Tiempo , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/terapia , Pueblos del Este de AsiaRESUMEN
Although the coronary chronic total occlusion (CTO) crossing algorithm has been published, the characteristics associated with the first strategy selection for short-length lesions <20 mm is still debatable. This study aimed to determine the characteristics associated with primary retrograde approach (PRA) for native CTO with short occlusion length in percutaneous coronary intervention (PCI). Between January 2014 and December 2021, we examined data on 4,088 lesions in the Japanese CTO-PCI Expert Registry with occlusion lengths <20 mm. Then, the characteristics for short-length CTO, which was performed by way of the PRA, were assessed. PRA was performed in 785 patients (19.2%). The guidewire success rate was 93.6%, and the technical success rate was 91.3%. Previous coronary artery bypass grafting, chronic kidney disease, and 6 lesion/anatomic characteristics (i.e., blunt stump, distal runoff <1 mm, CTO lesion tortuosity, reattempt procedures, ostial location, and the presence of collateral channel grade 2) were associated with PRA (p <0.05). Moreover, hemodialysis was an independent factor of unsuccessful anterograde guidewire crossing, along with distal runoff <1 mm, the existence of calcification, and CTO lesion tortuosity (all p <0.05). In clinical settings, these independent factors for PRA in short-length CTO can help in selecting the CTO-PCI strategy.
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Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Oclusión Coronaria/cirugía , Intervención Coronaria Percutánea/métodos , Japón , Factores de Riesgo , Angiografía Coronaria , Enfermedad Crónica , Factores de Tiempo , Sistema de Registros , Resultado del TratamientoRESUMEN
Background: Antegrade dissection and reentry (ADR) is an effective technique for wire passage in chronic total occlusion (CTO), and in recent years, the effectiveness of intravascular ultrasound (IVUS)-guided tip detection (TD)-ADR has been reported. However, the expansion of the subintimal space serves as a significant obstacle to the success of ADR, posing a limitation to the procedure. Case summary: We present the first case of using IVUS-guided TD-ADR with the subintimal transcatheter withdrawal (STRAW) technique. The patient was a 68-year-old Asian female with effort angina pectoris and a CTO in the middle section of the right coronary artery (RCA). Two previous attempts at percutaneous coronary intervention (PCI) for the RCA at another hospital were unsuccessful. During the third attempt PCI, the antegrade wire migrated into the subintimal space. To address this, we performed IVUS-guided TD-ADR using the Conquest Pro 12 Sharpened Tip (CP12ST; Asahi Intecc, Aichi, Japan) wire. However, due to the expansion of the subintimal space, we were unable to puncture the true lumen. To reduce the subintimal space, we employed the STRAW technique, which allowed successful puncture of the true lumen using the CP12ST wire. Finally, stenting was performed, resulting in satisfactory antegrade blood flow. Discussion: Intravascular ultrasound-guided TD provides accurate guidance for puncturing in ADR procedures, but the expansion of the subintimal space remains a significant challenge. The STRAW technique offers a solution by reducing the subintimal space and enabling successful puncture of the true lumen during IVUS-guided TD-ADR.
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Background: Chronic total occlusion (CTO) lesions contain various collateral channels. Only a few reports have described CTO with collateral channels from the bronchial arteries. Case summary: Herein, we report the case of a 59-year-old man with a left circumflex (LCX) coronary artery CTO with collateral channels from the bronchial arteries. The J-CTO score was 1. After confirming myocardial viability and myocardial ischaemia using a stress myocardial perfusion imaging test, we performed percutaneous coronary intervention for the CTO lesion. Successful revascularization was achieved by adopting the antegrade approach with the angiogram guidance of distal visualization using the bronchial artery. Discussion: Notably, there are no other reports of LCX CTO with collateral channels from the bronchial artery. Distal visualization of the distal true lumen is essential for the success of the antegrade approach. Furthermore, appropriate distal visualization helps to avoid unnecessary retrograde approaches and reduce complications.
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Background: Engagement of the guiding catheter (GC) for the coronary artery is sometimes difficult, depending on the patient's anatomy. The most suitable GC before percutaneous coronary intervention (PCI) in individual cases has not been determined yet. Case summary: An 81-year-old woman who had a right coronary artery chronic total occlusion had difficulty to engage the catheter for the right coronary artery in the first examination. Virtual reality (VR)-guided GC simulation before PCI using cardiac computed tomography (CT) could overcome the difficulty of GC engagement for the coronary artery and achieve procedure success. Discussion: VR-guided GC simulation has the potential to solve the catheter approach difficulty for any cardiovascular intervention.
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BACKGROUND: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is still challenging due to complex lesion morphology. Success rates may vary among the 3 major coronary arteries, influenced by clinical and angiographic characteristics. OBJECTIVES: This study sought to evaluate the differences in the predictors of unsuccessful PCI in first-attempt CTO lesions of the 3 major coronary arteries compared with the J-CTO (Japanese CTO) score. METHODS: This study assessed 6,408 first-attempt CTO patients from the Japanese CTO-PCI expert registry between January 2014 and December 2021, randomly assigned to derivation and validation sets. Difficulty scores for each artery were determined by assigning points to predictive unsuccessful factors. RESULTS: The CTO lesions were distributed as follows: left anterior descending coronary artery: 2,245 (35%), left circumflex coronary artery: 1,131 (18%), and right coronary artery (RCA): 3,032 (47%). Regarding success rates, left circumflex coronary artery CTO had the lowest procedural success rate (90%) followed by RCA CTO (92%) and left anterior descending coronary artery CTO (94%). RCA CTO was significantly longer and more severely angulated, requiring more often the retrograde approach. A multivariate logistic analysis revealed that predictors of failed PCI were different in CTO lesions among the 3 major coronary arteries, respectively. Moreover, our difficulty score for RCA CTO was superior to the J-CTO score in predicting unsuccessful PCI. CONCLUSIONS: Clinical and angiographic differences might explain the discrepancies of success rates in CTO lesions among the 3 major coronary arteries. Our novel difficulty score was comparable to the J-CTO score in predicting unsuccessful CTO-PCI with a superior discriminatory capacity.
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Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/patología , Resultado del Tratamiento , Intervención Coronaria Percutánea/efectos adversos , Angiografía Coronaria , Enfermedad Crónica , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Sistema de Registros , Factores de RiesgoRESUMEN
Contrast media exposure is associated with contrast-induced nephropathy (CIN) following percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Aim of this study is to assess the utility of minimum contrast media volume (CMV ≤ 50 mL) during CTO-PCI for CIN prevention in patients with chronic kidney disease (CKD). We extracted data from the Japanese CTO-PCI expert registry; 2863 patients with CKD who underwent CTO-PCI performed from 2014 to 2020 were divided into two groups: minimum CMV (n = 191) and non-minimum CMV groups (n = 2672). CIN was defined as an increased serum creatinine level of ≥ 25% and/or ≥ 0.5 mg/dL compared with baseline levels within 72 h of the procedure. In the minimum CMV group, the CIN incidence was lower than that in the non-minimum CMV group (1.0% vs. 4.1%; p = 0.03). Patient success rate was higher and complication rate was lower in the minimum CMV group than in the non-minimum CMV group (96.8% vs. 90.3%; p = 0.02 and 3.1% vs. 7.1%; p = 0.03). In the minimum CMV group, the primary retrograde approach was more frequent in the case of J-CTO = 1,2 and 3-5 groups compared to that in non-minimum CMV-PCI group (J-CTO = 0; 11% vs. 17.7%, p = 0.06; J-CTO = 1; 22% vs. 35.8%, p = 0.01; J-CTO = 2; 32.4% vs. 46.5%, p = 0.01; and J-CTO = 3-5; 44.7% vs. 80.0%, p = 0.02). Minimum CMV-PCI for CTO in CKD patients could reduce the incidence of CIN. The primary retrograde approach was observed to a greater extent in the minimum CMV group, especially in cases of difficult CTO.
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Oclusión Coronaria , Infecciones por Citomegalovirus , Intervención Coronaria Percutánea , Insuficiencia Renal Crónica , Humanos , Medios de Contraste/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/cirugía , Factores de Riesgo , Enfermedad Crónica , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Sistema de Registros , Angiografía Coronaria/efectos adversos , Resultado del TratamientoRESUMEN
A new chronic total occlusion (CTO) guidewire, Conquest Pro 12 Sharpened Tip (CP12ST), has a stronger penetration force than the original CP12 and a deflection effect that it does not have. The CP12ST enables us to advance into hard plaque that has not ever penetrated, which might change CTO treatment as shown in three cases.
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OBJECTIVES: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can improve patient symptoms, but it remains controversial whether it impacts subsequent clinical outcomes. METHODS: In this systematic review and meta-analysis, we queried PubMed, ScienceDirect, Cochrane Library, Web of Science, and Embase databases (last search: September 15, 2021). We investigated the impact of CTO-PCI on clinical events including all-cause mortality, cardiovascular death, myocardial infarction (MI), major adverse cardiovascular event (MACE), stroke, subsequent coronary artery bypass surgery, target-vessel revascularization, and heart failure hospitalizations. Pooled analysis was performed using a random-effects model. RESULTS: A total of 58 publications with 54,540 patients were included in this analysis, of which 33 were observational studies of successful vs failed CTO-PCI, 19 were observational studies of CTO-PCI vs no CTO-PCI, and 6 were randomized controlled trials (RCTs). In observational studies, but not RCTs, CTO-PCI was associated with better clinical outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause mortality, MACE, and MI were 0.52 (95% CI, 0.42-0.64), 0.46 (95% CI, 0.37-0.58), 0.66 (95% CI, 0.50-0.86), respectively for successful vs failed CTO-PCI studies; 0.38 (95% CI, 0.31-0.45), 0.57 (95% CI, 0.42-0.78), 0.65 (95% CI, 0.42-0.99), respectively, for observational studies of CTO-PCI vs no CTO-PCI; 0.72 (95% CI, 0.39-1.32), 0.69 (95% CI, 0.38-1.25), and 1.04 (95% CI, 0.46-2.37), respectively for RCTs. CONCLUSIONS: CTO-PCI is associated with better subsequent clinical outcomes in observational studies but not in RCTs. Appropriately powered RCTs are needed to conclusively determine the impact of CTO-PCI on clinical outcomes.
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Oclusión Coronaria , Infarto del Miocardio , Intervención Coronaria Percutánea , Humanos , Oclusión Coronaria/cirugía , Resultado del Tratamiento , Intervención Coronaria Percutánea/efectos adversos , Infarto del Miocardio/etiología , Oportunidad Relativa , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Observacionales como AsuntoAsunto(s)
Oclusión Coronaria , Intervención Coronaria Percutánea , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/epidemiología , Oclusión Coronaria/terapia , Humanos , Intervención Coronaria Percutánea/efectos adversos , Prevalencia , Resultado del TratamientoRESUMEN
Coronary perforations during chronic total occlusion percutaneous coronary intervention (CTO-PCI) are potential complications and reportedly associated with adverse events. This study aimed to describe the clinical characteristics and timing of perforations during CTO-PCI. Data from the Japanese CTO-PCI expert registry included 8,760 patients who underwent CTO-PCI between January 2014 and January 2019. The major adverse cardiac and cerebrovascular events were defined as death, tamponade, myocardial infarction, stent thrombosis, stroke, and revascularization. The guidewire manipulation time was defined as the time required to cross the CTO without perforation. Among these patients, 333 (3.8%) developed perforation during the CTO crossing attempt. Of the 333 patients, 29 developed cardiac tamponades (8.7%). Perforations more frequently occurred in a retrograde wiring than in an anterograde wiring (6.6% vs 1.7%, p <0.0001). A longer guidewire manipulation time was associated with the occurrence of perforation (median 101 minutes [interquartile range 59 to 150 minutes] in the perforation group vs 54.9 minutes [interquartile range 21.1 to 112.7 minutes] in the nonperforation group, p <0.0001). Risk factors for perforation were age, history of coronary bypass graft, right coronary artery lesion, de novo lesion, use of a stiff guidewire, and guidewire manipulation time of >60 minutes during anterograde wiring and age, non-left anterior descending artery lesion, use of a polymer-jacketed guidewire, and use of epicardial channel during retrograde wiring. In conclusion, risk factors for perforation were different between anterograde and retrograde wirings. A prolonged guidewire manipulation time was associated with the occurrence of perforation, especially during anterograde wiring.
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Oclusión Coronaria , Intervención Coronaria Percutánea , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/epidemiología , Oclusión Coronaria/cirugía , Humanos , Intervención Coronaria Percutánea/efectos adversos , Sistema de Registros , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background: Directional coronary atherectomy (DCA) revived in Japan since 2014. DCA is a special device to remove the atherosclerotic plaque of coronary artery in percutaneous coronary intervention (PCI). However, DCA procedure is recommended to perform by 8Fr system, which is one of the limitations of DCA. Case Series: Since transradial approach is the main access route for PCI, we considered how to perform DCA by TRA. The external diameter of 8Fr guiding catheter (GC) and 6Fr sheath are 2.70 and 2.67 mm. Then, if 6Fr sheath can be inserted without any resistance, 8Fr GC is considered to be insertable. We performed 5 cases of DCA by the transradial 8Fr sheathless GC approach, all cases were successful without discomfort associated with insertion and removal of the 8Fr GC. Conclusion: DCA by the transradial 8Fr sheathless GC approach might be one of options to avoid bleeding complication and serve more comfortable treatment for the patients.
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There have not been enough studies to examine the association between difference in operator experience and technical success rate in contemporary percutaneous coronary intervention for chronic total occlusion (CTO-PCI). The present study sought to provide insights into the impact of operator experience on clinical outcomes of CTO-PCI through a comparison of two largest Japanese CTO-PCI registries consisting of operators with different CTO-PCI experience. After combining clinical data from the Japanese CTO-PCI Expert Registry (ER) 2014-2016 (N = 4316) including CTO-PCI performed by highly experienced operators and the Retrograde Summit General Registry (RSGR) 2014-2016 (N = 2230) including CTO-PCI performed by less experienced operators, a pooled analysis was performed to compare clinical outcomes of CTO-PCI in 2 registries. The overall technical success rate and the incidence of in-hospital major adverse events were comparable between ER and RSGR (90.1% vs 88.9%, p = 0.133, 1.7% vs 1.5%, p = 0.606, respectively). Technical success rate in ER was significantly higher among the patients treated with primary antegrade approach (91.8% vs 89.5%, p = 0.009), whereas there was no significant difference among the patients treated with the primary retrograde approach (85.7% vs 85.3%, p = 0.857). Multivariate analysis suggested ER operator could not be an independent predictor for technical success. CTO-PCI performed by less experienced but appropriately trained operators could achieve similarly high technical success rate with comparable safety compared with those performed by highly experienced specialists in contemporary Japanese context.
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Oclusión Coronaria , Intervención Coronaria Percutánea , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/terapia , Humanos , Japón/epidemiología , Intervención Coronaria Percutánea/efectos adversos , Sistema de Registros , Factores de Riesgo , Resultado del TratamientoRESUMEN
Remarkable progress has been achieved in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in recent years, with refinement of the indications and technical aspects of the procedure, imaging, and complication management. Randomized controlled trials and rigorous prospective registries have provided high-quality data on the benefits and risks of CTO PCI. Global collaboration has led to an agreement on nomenclature, indications, endpoint definition, and principles of clinical trial design that have been distilled in global consensus documents such as the CTO Academic Research Consortium. Increased use of preprocedural coronary computed tomography angiography and intraprocedural intravascular imaging, as well as development of novel techniques and structured CTO crossing and complication management algorithms, allow a systematic, stepwise approach to this difficult lesion subset. This state-of-the-art review provides a comprehensive discussion about the most recent developments in the indications, preprocedural planning, technical aspects, complication management, and future directions of CTO PCI.
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Oclusión Coronaria , Intervención Coronaria Percutánea , Enfermedad Crónica , Angiografía Coronaria/métodos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Estudios Prospectivos , Sistema de Registros , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Directional coronary atherectomy (DCA) was revived in Japan in 2014. DCA is a special procedure to remove the atherosclerotic plaque of coronary artery during percutaneous coronary intervention. We present the case of a 91-year-old woman with symptoms of angina. Coronary angiography revealed significant stenosis with a slit lesion of the proximal left anterior descending artery. Because she had a high risk of bleeding, we did not want to implant a stent to prevent bleeding events. Then, we performed optical coherence tomography (OCT) and intravascular ultrasound to evaluate the morphology of the slit lesion in more detail. OCT showed clearly that the direction of the flap was counterclockwise and the edge of the flap was located in the epicardium. Since we could understand the localization of plaque distribution fully by OCT examination, we successfully removed the flap by DCA based on information from OCT. After that, we performed balloon dilatation with a 3.0-mm drug-coated balloon and finished without implanting the stent successfully. Her symptoms completely disappeared and postoperative course was good. DCA supported with OCT might be one of the options in high bleeding risk patients, suggesting a potential stent-less therapeutic option.
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PURPOSE: The endovascular approach for eccentric calcified lesions of the no-stenting zone is challenging. This study aimed to investigate the effect of a novel technique for these lesions. METHODS: We performed EVT for severe and eccentric calcified lesions using the technique, which is presented previously and named aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA). In brief, a guidewire is passed to the residual lumen firstly. Next, another guidewire is advanced into and cross through the calcified plaque and returned to the distal original lumen with intravascular ultrasound (IVUS) guided. The calcified plaque is dilated by using a scoring-balloon or non-compliant balloon. RESULTS: Consecutive 14 peripheral artery disease patients with isolated and eccentric calcification in a no-stenting zone were treated using ARCADIA technique between January 2018 and March 2020. In IVUS data, lumen cross-section area was significantly increased from 5.2 ± 2.0 mm2 to 18.1 ± 6.9 mm2 (p < 0.01), lumen area was expanded roundly evaluating as symmetry index from 0.45 ± 0.09 to 0.81 ± 0.12 (p < 0.01). There were no distal embolization and perforation after ARCADIA technique. One-year target lesion revascularization occurred in only 2 cases. The primary patency of 1 year was 85.7%. CONCLUSION: ARCADIA technique is safe and appropriate, and can be 1 option to treat for eccentric calcified lesions of the no-stenting zone as an optimal wire crossing method.