Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention.

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

[Percutaneous treatment of coronary chronic total occlusions]. / Sepelvaltimon kroonisen totaalitukoksen perkutaaninen hoito.

Chronic total occlusions (CTOs) are frequently detected on diagnostic coronary angiograms. For the selection of patients for CTO percutaneous coronary intervention, factors such as the level of symptoms, level of myocardial viability and extent of ischemia must be taken into account. Remarkable progress has been achieved in the success of complex CTO procedures during the past decade. In addition to antegrade wire escalation strategy, subintimal passage of the guidewire with or without dissection and re-entry techniques and retrograde techniques can be utilized. After successful wiring of the lesion, balloon angioplasty and stenting comparable to a non-CTO lesion are performed.

Interrelation between the extent of atherosclerosis in the thoracic aorta, carotid intima-media thickness and the extent of coronary artery disease.

Intima-media thickness (IMT) of the common carotid artery and atherosclerosis of the thoracic aorta have been shown to correlate with coronary artery disease (CAD). This study compares the relation between wall changes in the thoracic aorta and the carotid arteries and the angiographic severity and extent of atherosclerotic lesions in the coronary arteries in patients with verified CAD. Atherosclerotic wall changes in the carotid arteries and the thoracic aorta were measured by B-mode ultrasonography and transesophageal echocardiography (TEE), respectively, in 37 subjects aged 65+/-10 years with angiographically verified CAD. The mean value of the common carotid IMT of the right and left sides was 0.87+/-0.21 mm. All subjects had carotid plaques. TEE detected grades II-IV atherosclerotic plaques in the thoracic aorta in 32 of the 37 (86%) patients. A significant correlation was seen between the extent of coronary artery stenosis and aortic plaques score (r=0.46, p=0.008). Mean carotid IMT was also significantly correlated with coronary artery stenosis extent score (r=0.44, p=0.007). Moreover, a significant correlation was seen between the aortic plaque score and the mean carotid IMT (r=0.39, p=0.02). In conclusion, we found a clear and significant relationship between wall changes in the thoracic aorta, common carotid IMT and the angiographic extent of coronary artery stenosis in patients with severe CAD. These findings indicate a potential of B-mode ultrasonography of the carotid arteries and transesophageal echocardiographic aortic examination in the diagnostic and prognostic evaluation of patients with suspected CAD.

Morphological changes rather than flow-mediated dilatation in the brachial artery are better indicators of the extent and severity of coronary artery disease.

OBJECTIVES: The aim of this study was to examine the relationship between morphological and functional parameters of the brachial and carotid arteries and the angiographic extent and severity of coronary artery stenosis in patients with severe coronary artery disease (CAD). DESIGN: A cross-sectional study. SETTING: University hospital. MAIN OUTCOME MEASURES: Flow-mediated dilatation (FMD), intima-media thickness (IMT) in the brachial artery and atherosclerotic wall changes in the carotid arteries were measured by B-mode high-resolution ultrasound in 58 patients who had undergone coronary angiography. RESULTS: A significant correlation was seen between the extent of coronary artery stenosis defined as the coronary angiographic score and both the mean brachial artery IMT and intima-media area (IMa; P = 0.01 and P = 0.04, respectively). There was no significant correlation between FMD and the extent of coronary artery stenosis. A significant correlation was seen between the mean carotid artery IMT and the mean brachial artery IMT (r = 0.30, P = 0.03). However, there was no significant correlation between FMD and the mean carotid artery IMT or IMa (r = 0.16, P = 0.23 and r = 0.17, P = 0.24, respectively). CONCLUSIONS: Morphological but not functional parameters of the brachial artery are associated with the extent of coronary artery stenosis and atherosclerotic wall changes in the carotid arteries in patients with severe CAD. These findings indicate a potential of B-mode ultrasonography of morphological parameters in the brachial artery in the diagnostic and prognostic evaluation of patients with suspected CAD.

Chronic total occlusions in Sweden--a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).

INTRODUCTION: Evidence for the current guidelines for the treatment of patients with chronic total occlusions (CTO) in coronary arteries is limited. In this study we identified all CTO patients registered in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and studied the prevalence, patient characteristics and treatment decisions for CTO in Sweden. METHODS AND RESULTS: Between January 2005 and January 2012, 276,931 procedures (coronary angiography or percutaneous coronary intervention) were performed in 215,836 patients registered in SCAAR. We identified all patients who had 100% luminal diameter stenosis known or assumed to be ≥ 3 months old. After exclusion of patients with previous coronary artery bypass graft (CABG) surgery or coronary occlusions due to acute coronary syndrome, we identified 16,818 CTO patients. A CTO was present in 10.9% of all coronary angiographies and in 16.0% of patients with coronary artery disease. The majority of CTO patients were treated conservatively and PCI of CTO accounted for only 5.8% of all PCI procedures. CTO patients with diabetes and multivessel disease were more likely to be referred to CABG. CONCLUSION: CTO is a common finding in Swedish patients undergoing coronary angiography but the number of CTO procedures in Sweden is low. Patients with CTO are a high-risk subgroup of patients with coronary artery disease. SCAAR has the largest register of CTO patients and therefore may be valuable for studies of clinical importance of CTO and optimal treatment for CTO patients.

Speckle tracking echocardiography is a sensitive tool for the detection of myocardial ischemia: a pilot study from the catheterization laboratory during percutaneous coronary intervention.

Analysis of rotational myocardial motion has been reported to be a sensitive index of myocardial ischemia. In this study, circumferential and radial myocardial strain and displacement was monitored during angioplasty balloon-induced myocardial ischemia in 8 patients undergoing percutaneous coronary intervention. The circumferential and radial variables were measured simultaneously in parasternal short-axis view at the papillary muscle level using the recently introduced speckle tracking echocardiography technique that allows 2-dimensional, angle-independent, real-time evaluation of the myocardial motion (2-dimensional strain modality). Acute regional myocardial ischemia caused a significant reduction of circumferential (-35.6 +/- 23.1%) and radial (-27.1 +/- 23.2%) strain and displacement (-49.6 +/- 27.2% and -43.2 +/- 26.8%, respectively). Simultaneously, time to the respective peak systolic values became significantly prolonged, the circumferential ischemic response in temporal domain being more pronounced (P < .05). Speckle tracking echocardiography-based analysis of rotational myocardial motion has a potential to become an efficient clinical bedside tool in the detection of acute ischemic regional myocardial dysfunction.