Percutaneous Coronary Intervention for Aorto-Ostial Chronic Total Occlusion: Evaluating Lesion Complexity and Procedural Outcomes.

BACKGROUND: PCI for aorto-ostial CTO remains challenging. The techniques for guidewire in aorto-ostial CTO may differ from those used in non-aorto-ostial CTOs, influenced by clinical and angiographic characteristics. OBJECTIVES: This study aimed to assess the technical aspects and outcomes of percutaneous coronary intervention (PCI) in patients with aorto-ostial chronic total occlusion (CTO). METHODS: This analysis included 420 patients with ostial CTO from the Japanese CTO-PCI Expert Registry, spanning January 2014 to December 2022. It examined the strategies and procedural outcomes of CTO PCI. RESULTS: Ostial CTO represented 420 of 10,814 (3.9%) of all CTO PCI cases. Within this subset, aorto-ostial CTO accounted for 218 of 420 (52%) cases. The technical success rate for aorto-ostial CTO was 88% (191/218). Aorto-ostial CTOs exhibited longer lesion lengths and were more likely to present with challenges such as distal target lumen ambiguity, calcification, and tortuosity compared with non-aorto-ostial CTOs. The retrograde approach was more commonly used in aorto-ostial CTO, with retrograde direct crossing being the most successful technique, especially in cases of flush CTO. A multivariate logistic analysis identified several factors significantly associated with unsuccessful aorto-ostial CTO PCI, including difficulties in engaging a guiding catheter, estimating the collateral channel (as assessed by the J-Channel score), and tortuosity. CONCLUSIONS: Aorto-ostial CTOs are more complex and frequently require a retrograde approach. The availability of suitable interventional collateral channels is crucial for the success of these procedures.

Knuckle Guidewires to Create Dissections in Chronic Total Occlusion Percutaneous Coronary Intervention: Position Statement.

Dissection and re-entry techniques are essential to achieve safe and effective chronic total occlusion recanalization. Several studies have demonstrated similar outcomes following extraplaque stenting compared with intraplaque stenting. Dissection techniques most often involve the use of knuckled wires to progress within and beyond the chronic total occlusion segment. In this expert consensus document, the authors compare the properties of different polymer-jacketed wires for their use in dissection techniques. The authors also describe 2 principal knuckle wire behaviors, the rolling and the traveling knuckles. Finally, several adjunctive techniques for safer dissection are described.

Reclassification of CTO Crossing Strategies in the ERCTO Registry According to the CTO-ARC Consensus Recommendations.

BACKGROUND: The CTO-ARC (Chronic Total Occlusion Academic Research Consortium) recognized that a nonstandardized definition of chronic total occlusion (CTO) percutaneous coronary intervention approaches can bias the complications' attribution to each crossing strategy. OBJECTIVES: The study sought to describe the numbers, efficacy, and safety of each final CTO crossing strategy according to CTO-ARC recommendations. METHODS: In this cross-sectional study, data were retrieved from the European Registry of Chronic Total Occlusions between 2021 and 2022. RESULTS: Out of 8,673 patients, antegrade and retrograde approach were performed in 79.2% and 20.8% of cases, respectively. The antegrade approach included antegrade wiring and antegrade dissection and re-entry, both performed with or without retrograde contribution (antegrade wiring without retrograde contribution: n = 5,929 [68.4%]; antegrade wiring with retrograde contribution: n = 446 [5.1%]; antegrade dissection and re-entry without retrograde contribution: n = 353 [4.1%]; antegrade dissection and re-entry with retrograde contribution: n = 137 [1.6%]). The retrograde approach included retrograde wiring (n = 735 [8.4%]) and retrograde dissection and re-entry (n = 1,073 [12.4%]). Alternative antegrade crossing was associated with lower technical success (70% vs 86% vs 93.1%, respectively; P < 0.001) and higher complication rates (4.6% vs 2.9% vs 1%, respectively; P < 0.001) as compared with retrograde and true antegrade crossing. However, alternative antegrade crossing was applied mostly as a rescue strategy (96.1%). CONCLUSIONS: The application of CTO-ARC definitions allowed the reclassification of 6.7% of procedures as alternative antegrade crossing with retrograde or antegrade contribution which showed higher MACCE and lower technical success rates, as compared with true antegrade and retrograde crossing.

Successful management of acute left main coronary occlusion following transcatheter aortic valve implantation: a case report.

BACKGROUND: Transcatheter aortic valve implantation is an established, highly effective procedure in selected patients with severe degenerative aortic valve stenosis at high risk for conventional surgery. CASE PRESENTATION: We report a case of a 74-year-old Caucasian man who had an acute left main occlusion after transcatheter implantation of balloon-expandable valve prosthesis, followed by coronary intervention with successful recanalization. CONCLUSIONS: Acute coronary occlusion is a rare life-threatening complication of transcatheter aortic valve implantation that is poorly predictable and requires immediate diagnosis and treatment.

Uncommon culprit artery leading to atypical de winter electrocardiographic changes: a case report.

BACKGROUND: A subset of patients with acute coronary artery occlusion requiring emergency revascularization, does not present with the typical ECG features of ST-segment elevation myocardial infarction (STEMI).Timely identification of these atypical presentations is crucial. CASE PRESENTATION: This report describes a 55-year-old male patient who was admitted to the emergency department with chest pain. The electrocardiogram (ECG) recorded atypical de Winter electrocardiographic changes and their evolution. RESULTS: Coronary angiography confirmed the occlusion of the second diagonal branch (D2). The patient's condition improved after D2 balloon angioplasty. CONCLUSION: De Winter electrocardiographic changes can also be observed in D2 occlusions and may present with milder manifestations. Timely recognition of these changes holds significant clinical value.

Use of dual-lumen microcatheter pullback injection in complex percutaneous coronary intervention.

Dual-lumen microcatheters (DLMC) are utilized in challenging wiring scenarios as well as for contrast and medication injections. Nonetheless, lesion characterization remains extremely challenging in many cases. We describe a DLMC-facilitated technique which can assist in locating the distal anastomosis while navigating an occluded bypass graft during retrograde chronic total occlusion recanalization, as well as in the differential diagnosis of abrupt vessel closure. This "DLMC Pullback Injection" technique is performed by injecting contrast through the over-the-wire port of the DLMC, while the latter is quickly pulled back across the region of interest in a dynamic fashion. We believe this technique has the potential to solve challenging scenarios and to enrich the complex percutaneous coronary intervention operator's armamentarium.

Intravascular lithotripsy in heavily calcified chronic total occlusion: procedural and one-year clinical outcomes.

BACKGROUND: Calcification within chronic total occlusions (CTO) is strongly associated with worse outcomes. Despite the excellent success and safety of intravascular lithotripsy (IVL) in heavily calcified lesions, evidence in CTO remains scarce. AIM: This study aimed to evaluate the procedural and long-term clinical outcomes of IVL in heavily calcified CTO. METHODS: Patients who underwent IVL between 2019 and 2024 from an ongoing prospective multicenter registry were eligible for inclusion. Patients were therefore classified in CTO and non-CTO groups. The efficacy and safety endpoints of CTO percutaneous coronary interventions were defined according to the CTO-ARC consensus. In-hospital major adverse cardiovascular events (MACE) included cardiac death, nonfatal myocardial infarction and target lesion revascularization (TVR). RESULTS: A total of 404 patients underwent IVL, of which the treated lesion was a CTO in 33 (8.2%). The mean J-CTO score was 2.3 ± 1.1. Device success showed no significant difference between CTO and non-CTO groups (100% vs 98.4%; p = 0.35). Comparable technical success with residual stenosis <30% was observed in both groups (90.1% in CTO vs 89.2% in non-CTO, p = 0.83). The incidence of MACE was similar across groups during hospital stays (CTO 6.0% vs. non-CTO 1.9%, p = 0.12), at 30-day (CTO 9.1% vs. non-CTO 3.0%, p = 0.07), and at 12-month follow-up (CTO 9.1% vs. non-CTO 7.3%, p = 0.70). CONCLUSION: IVL provides high procedural success and consistent clinical outcomes in both CTO and non-CTO cases, reinforcing its role in managing heavily calcified coronary lesions.

Radiomics Analysis of CTO Plaques for Predicting Successful Guidewire Crossing Within 30 Minutes of PCI.

BACKGROUND: Coronary computed tomography angiography provides valuable information for evaluating the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention. This study aimed to investigate the value of CTO plaque characteristics derived from radiomics analysis for predicting the difficulty of percutaneous coronary intervention. METHODS: Patients with CTO were retrospectively enrolled from a hospital as training and internal test sets and from the other 2 territory hospitals as external test sets. Radiomics characteristics were extracted from the CTO segment on coronary computed tomography angiography. Radiomics and combined models were developed to predict successful guidewire crossing within 30 minutes (guidewire success) of CTO percutaneous coronary intervention. Subgroup analysis was conducted to investigate the influence of potential risk factors on the radiomics model performance. RESULTS: A total of 551 patients (median, 60; interquartile range, 52.00-66.00 years, 460 men) with 565 CTO lesions were finally enrolled. In the training, internal test, and external test sets, 203 of 357, 85 of 149, and 38 of 59 CTO lesions achieved guidewire success, respectively. Six radiomics features were selected for constructing the radiomics model. In the external test set, the area under the receiver operating characteristic curve of the radiomics model was significantly higher than prior prediction models (P<0.05 for all) with the area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity of 0.86, 74.58%, 81.58%, and 61.90%, respectively. The performance of the radiomics model was dependent on calcification, CTO location, adjacent branch(es), and operator caseload. CONCLUSIONS: CTO characteristics revealed by radiomics analysis can be used as effective imaging biomarkers for predicting guidewire success. However, the performance of the radiomics model depends on anatomic and operator factors.

Conquering the obstacles during the intervention of a proximal chronic total occlusion of right coronary artery with a concurrent significant ostial stenosis: a case report.

Percutaneous coronary intervention (PCI) on a proximal chronic total occlusion (CTO) of the right coronary artery (RCA) with concurrent ostial stenosis can be challenging because of the significant difficulty in properly engaging the catheter and providing stable support during the procedure. We report the case of a 57-year-old man with chronic coronary syndrome who underwent an elective PCI at the Dr. Soetomo General Hospital in Surabaya, on April 13th, 2022. At the beginning of the procedure, there was difficulty in intubating the RCA, which required the guide catheter replacement. The angiography revealed a significant lesion at the ostium, a CTO at proximal to mid- RCA with bridging collaterals, and a significant distal lesion. Several strategies to improve guiding catheter support during PCI are using large and supportive shape guide catheters, deep guide catheter intubation, extra support wire, microcatheter and guide catheter extension. The risk of pressure dampening and ischaemia upon engagement should always be kept under consideration.

[Life insurance after percutaneous revascularization in a patient with severe left ventricular dysfunction and left bundle branch block: benefit of revascularization in the post-REVIVED-BCIS2 era]. / Un'assicurazione sulla vita dopo rivascolarizzazione percutanea in un paziente con severa disfunzione ventricolare sinistra e blocco di branca sinistro: beneficio della rivascolarizzazione coronarica nell'era post-REVIVED-BCIS2.

The recent results of the REVIVED-BCIS2 randomized clinical trial added further controversy on the utility of myocardial revascularization in patients with chronic coronary syndrome with reduced ejection fraction. However, coronary artery disease still represents the leading cause of heart failure with reduced ejection fraction, with the potential for functional recovery following complete revascularization due to the restoration of the so-called hibernating myocardium. We report an emblematic case of a patient with recovery of contractile function and normalization of the left bundle branch block after percutaneous coronary intervention of the right coronary artery chronic total occlusion.

Predicting Successful Chronic Total Occlusion Crossing With Primary Antegrade Wiring Using Machine Learning.

BACKGROUND: There is limited data on predicting successful chronic total occlusion crossing using primary antegrade wiring (AW). OBJECTIVES: The aim of this study was to develop and validate a machine learning (ML) prognostic model for successful chronic total occlusion crossing using primary AW. METHODS: We used data from 12,136 primary AW cases performed between 2012 and 2023 at 48 centers in the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) to develop 5 ML models. Hyperparameter tuning was performed for the model with the best performance, and the SHAP (SHapley Additive exPlanations) explainer was implemented to estimate feature importance. RESULTS: Primary AW was successful in 6,965 cases (57.4%). Extreme gradient boosting was the best performing ML model with an average area under the receiver-operating characteristic curve of 0.775 (± 0.010). After hyperparameter tuning, the average area under the receiver-operating characteristic curve of the extreme gradient boosting model was 0.782 in the training set and 0.780 in the testing set. Among the factors examined, occlusion length had the most significant impact on predicting successful primary AW crossing followed by blunt/no stump, presence of interventional collaterals, vessel diameter, and proximal cap ambiguity. In contrast, aorto-ostial lesion location had the least impact on the outcome. A web-based application for predicting successful primary AW wiring crossing is available online (PROGRESS-CTO website) (https://www.progresscto.org/predict-aw-success). CONCLUSIONS: We developed an ML model with 14 features and high predictive capacity for successful primary AW in chronic total occlusion percutaneous coronary intervention.

Beyond STEMI-NSTEMI Paradigm: Dante Pazzanese's Proposal for Occlusion Myocardial Infarction Diagnosis. / Além do Paradigma IAMCSST-IAMSSST: Proposta do Instituto Dante Pazzanese para o Diagnóstico de Oclusão Coronariana Aguda.

Although the existing framework for classifying acute myocardial infarction (AMI) into STEMI and NSTEMI has been beneficial, it is now considered to be falling short in addressing the complexity of acute coronary syndromes. The study aims to scrutinize the current STEMI-NSTEMI paradigm and advocate for a more nuanced framework, termed as occlusion myocardial infarction (OMI) and non-occlusion myocardial infarction (NOMI), for a more accurate diagnosis and management of AMI. A comprehensive analysis of existing medical literature was conducted, with a focus on the limitations of the STEMI-NSTEMI model. The study also outlines a new diagnostic approach for patients presenting with chest pain in emergency settings. The traditional STEMI-NSTEMI model falls short in diagnostic precision and effective treatment, especially in identifying acute coronary artery occlusions. The OMI-NOMI framework offers a more anatomically and physiologically accurate model, backed by a wealth of clinical research and expert opinion. It underscores the need for quick ECG assessments and immediate reperfusion therapies for suspected OMI cases, aiming to improve patient outcomes. The OMI-NOMI framework offers a new avenue for future research and clinical application. It advocates for a more comprehensive understanding of the underlying mechanisms of acute coronary syndromes, leading to individualized treatment plans. This novel approach is expected to ignite further scholarly debate and research, particularly in the Brazilian cardiology sector, with the goal of enhancing diagnostic accuracy and treatment effectiveness in AMI patients.

Embora o modelo existente de classificação do infarto agudo do miocárdio (IAM) em IAMCSST e IAMSSST tenha sido benéfico, considera-se hoje que ele falha em abordar a complexidade das síndromes coronarianas agudas. O estudo tem como objetivo examinar o atual paradigma IAMCSST-IAMSSST e defender um modelo mais detalhado, chamado de oclusão coronariana aguda (OCA) e Ausência de Oclusão Coronária Aguda (NOCA), para um diagnóstico e um manejo do IAM mais precisos. Realizou-se uma análise abrangente da literatura médica existente, com foco nas limitações do modelo IAMCSST-IAMSSST. O estudo também descreve uma nova abordagem diagnóstica para pacientes apresentando do torácica nos departamentos de emergência. O modelo IAMCSST-IAMSSST tradicional falha em prover um diagnóstico preciso e um tratamento efetivo, principalmente na identificação de oclusões da artéria coronária. O modelo OCA-NOCA é mais preciso em termos anatômicos e fisiológicos, e apoiado por pesquisa clínica extensa e opiniões de especialistas. Ele destaca a necessidade de rápida realização de eletrocardiogramas (ECGs) e terapias de reperfusão para casos suspeitos de OCA, visando melhorar os desfechos dos pacientes. O modelo OCA-NOCA abre um novo caminho para pesquisas e aplicações clínicas futuras. Ele defende um entendimento mais abrangente dos mecanismos subjacentes das síndromes coronarianas agudas, levando a planos individualizados de tratamentos. Espera-se que essa nova abordagem incite novos debates e pesquisas acadêmicas, principalmente na área de cardiologia no Brasil, com o objetivo de aumentar a precisão diagnóstica e a eficácia do tratamento de pacientes com IAM.

Successful revascularization of coronary occlusion due to lotus root-like plaques by IVUS-based real-time three-dimensional wiring using the tip detection method in a patient with cardiac arrest.

A 32-year-old man, who was treated for T-cell lymphoma, presented in cardiac arrest. He had been treated for heart failure with reduced ejection fraction. Veno-arterial extracorporeal membrane oxygenation was initiated immediately. We diagnosed him as non-ST elevated myocardial infarction. Coronary angiography demonstrated the occlusion of the trifurcation in the proximal left anterior descending artery (LAD). We failed to advance the first guidewire into the distal LAD by angio-based conventional wiring. Intravascular ultrasonography (IVUS) of the proximal diagonal branch revealed two diaphragms separating the distal lumen without connection, which looks like lotus root-like appearance. We quickly penetrated the plaque using IVUS-based real-time 3D wiring using the tip detection method. The contrast injection via the microcatheter showed the distal diagonal branch (D2). After the balloon dilation in D2, IVUS image revealed a torn plaque between D2 and the distal LAD. Subsequently we advanced the guidewire to the distal LAD using IVUS-based real-time 3D wiring using the tip detection method through the tear of the plaque. Finally, we successfully performed the revascularization of LAD in a preferable procedure time. The patient recovered well and was discharged 39 days after cardiac arrest. This case highlights the efficacy of IVUS-based real-time 3D wiring using the tip detection method even in the emergent and challenging situation.