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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
Antegrade wiring is the dominant method used in chronic total occlusion percutaneous coronary intervention (CTO PCI). However, distal cap puncture for distal true lumen wiring remains a significant barrier toward success. Three-dimensional (3D) fluoroscopic wiring can improve the speed, safety, and success of distal cap wiring. In this article, we provide 10 tips for every CTO interventionist to use when performing 3D wiring in distal true lumen wiring.
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We report the Extraplaque Blood Withdrawal stenting technique to treat chronic total occlusion percutaneous coronary intervention (CTO PCI)-induced extraplaque hematoma.
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Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/cirugía , Enfermedad Crónica , Resultado del Tratamiento , Angiografía Coronaria , Factores de Tiempo , Hematoma/diagnóstico , Hematoma/etiologíaRESUMEN
PCI in the setting of previous aorto-ostial stenting can be difficult, especially if there is excessive stent protrusion. Various techniques have been described, including double-wire technique, double-guide snare technique, side-strut sequential ballooning technique, and guide extension facilitated sidestrut stenting. These techniques can sometimes be complicated, and intervention through a side-strut may lead to excessive stent deformation or avulsion of the protruding segment. Our novel technique uses a dual-lumen catheter and floating wire to back the JR4 guide away from the protruding stent while maintaining stability for another guidewire to enter the central lumen.
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Intervención Coronaria Percutánea , Humanos , Catéteres , StentsRESUMEN
BACKGROUND: Severe coronary artery calcification (CAC) remains challenging during percutaneous coronary intervention (PCI) and often requires 1 or more advanced calcium modification tools. OBJECTIVES: We describe the combination use of rotational (RA) or orbital atherectomy (OA), with intravascular lithotripsy (IVL), termed rotatripsy and orbital-tripsy, respectively, for modifying CAC prior to stent implantation during PCI. METHODS: We performed a retrospective analysis of patients treated with rotatripsy or orbital-tripsy at our center between July 2019 and March 2022. The primary efficacy endpoint was procedural success (successful stent implantation, <30% residual stenosis visually, Thrombolysis in Myocardial Infarction 3 flow; absence of types C to F dissection/perforation or loss of side branch ≥2.0mm visually) without in-hospital major adverse cardiovascular event (MACE, defined as cardiovascular death, myocardial infarction [MI], target-vessel revascularization). RESULTS: A total of 25 patients (14 rotatripsy and 11 orbital-tripsy) were included in our study. The mean age was 72.2 ± 7.6 years and 76% were men. PCI was guided by intravascular imaging in 24 patients (96%). All cases were treated with either RA or OA before utilization of IVL. Procedural success was achieved in 22 cases (88%) with 1 sidebranch loss without periprocedural MI (4%) and 2 in-patient deaths (8%) unrelated to the procedure (1 intracerebral hemorrhage and 1 cardiac arrest). CONCLUSION: We describe efficacious use of both rotatripsy and orbital-tripsy to modify severe CAC during PCI in a real-world setting. Intravascular imaging can guide appropriate use of these devices to complement each other to modify severe CAC to achieve optimal outcomes.
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Aterectomía Coronaria , Enfermedad de la Arteria Coronaria , Litotricia , Infarto del Miocardio , Intervención Coronaria Percutánea , Calcificación Vascular , Masculino , Humanos , Persona de Mediana Edad , Anciano , Femenino , Intervención Coronaria Percutánea/métodos , Aterectomía Coronaria/métodos , Calcio , Estudios Retrospectivos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Resultado del Tratamiento , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/cirugía , Infarto del Miocardio/etiología , Aterectomía , Calcificación Vascular/diagnóstico , Calcificación Vascular/cirugía , Angiografía Coronaria/métodosRESUMEN
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 AsuntoRESUMEN
Coronary artery perforation is a rare but serious complication during percutaneous coronary intervention. Distal or small vessel perforation is usually treated by coil, fat, or microsphere embolization. We describe 5 cases of distal coronary perforation that were managed successfully by a novel technique that uses absorbable sutures. (Level of Difficulty: Advanced.).
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The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.
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Algoritmos , Angiografía Coronaria , Oclusión Coronaria/cirugía , Intervención Coronaria Percutánea , Oclusión Coronaria/diagnóstico por imagen , HumanosAsunto(s)
Oclusión Coronaria , Rajidae , Animales , Catéteres Cardíacos , Humanos , Resultado del TratamientoRESUMEN
OBJECTIVES: Transcatheter aortic valve implantation is a recognized treatment for patients with severe aortic stenosis at all risk groups. However, permanent pacemaker rates remain high for self expandable transcatheter valves and permanent pacemaker implantation has been associated with increased morbidity. In this analysis we aim to evaluate short term clinical outcomes post self expandable transcatheter aortic valve implantation and determine risk factors for permanent pacemaker implantation. METHODS: 88 patients with severe aortic stenosis with transcatheter aortic valve implantation performed between the year 2016-2018 were retrospectively analyzed. Outcomes of interest included 1- year all cause mortality, 30-day major adverse cardiovascular events, permanent pacemaker and paravalvular leak rates. Survival analysis was performed with Kaplan Meier analysis and risk factors for survival and permanent pacemaker rates were identified with log rank test and regression analysis. RESULTS: The mean age of the cohort was 80.3 +/- 6.9 years. The mean STS score was 9.25. The 30 day all-cause mortality was 5.7% and 1-year all cause mortality was 16.7%. 80 patients had transfemoral transcatheter aortic valve implantation, and a majority of the patients (85.2%) were implanted with Corevalve Evolut R device. The device success rate was 88.6%. Multivariate analysis identified concomitant severe coronary artery disease (OR = 18.2 +/- 0.9; P = 0.002), pre transcatheter aortic valve implantation atrial fibrillation (OR = 8.6 +/- 0.91; P = 0.02) and post procedural disabling stroke (OR = 32.6 +/- 1.35; P = 0.01) as risk factors for 1-year mortality. The 30-day pacemaker rate was 17.6%. The presence of right bundle branch block (OR 11.1 +/- 0.86; P = 0.005), non-coronary cusp implantation depth (OR = 1.34 +/- 0.15; P = 0.05) and a non coronary cusp implantation depth / membranous septal length ratio of more than 50% were associated with post procedural pacemaker implantation (OR = 29.9 +/- 1.72; P = 0.05). Among the 15 patients with post procedural pacemaker implantation, 40% were found to be non-pacemaker dependent at 1 year. CONCLUSION: Short term outcomes of transcatheter aortic valve implantation in severe aortic stenosis patients are promising. Pacemaker rates remain high. More studies are needed to evaluate the factors that influence pacemaker rates and dependence to further improve transcatheter aortic valve implantation outcomes.
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Estenosis de la Válvula Aórtica/cirugía , Bloqueo de Rama/epidemiología , Bloqueo Cardíaco/epidemiología , Complicaciones Posoperatorias/epidemiología , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/epidemiología , Fibrilación Atrial/epidemiología , Estimulación Cardíaca Artificial , Comorbilidad , Enfermedad de la Arteria Coronaria/epidemiología , Femenino , Bloqueo Cardíaco/terapia , Prótesis Valvulares Cardíacas , Humanos , Masculino , Oportunidad Relativa , Marcapaso Artificial , Complicaciones Posoperatorias/terapia , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Resultado del TratamientoRESUMEN
We at the Asia Pacific Chronic Total Occlusion (APCTO) club, provide this review to address the gap between reverse controlled antegrade and retrograde subintimal tracking (CART) and antegrade wire access. We describe the usual method for wire externalisation. We then address how to deal with failure to wire the proximal part of the chronic total occlusion (CTO) vessel or the guiding catheter. After successful antegrade guiding catheter wiring, we address the problem of failing to cross the CTO body with the retrograde microcatheter and we recommend the use of a retrograde small balloon, reversion to traditional CART, retrograde knuckle wiring into the subintimal space and antegrade scratch and go, and external cap crush. We also propose rendezvous type tip-in and describe the way to do this to overcome problems. In conclusion, we review and make recommendations for methods to gain antegrade wire access after successful reverse CART. We have addressed each failure mode in detail covering the different options, balancing risks and success rates. Our recommendations focus upon safety first and ease of use. We hope this work will help all retrograde operators to further improve the safety, efficacy, and success rates of their retrograde procedures.
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BACKGROUND: The use of a retrograde approach and algorithm-driven CTO (chronic total occlusion) percutaneous coronary intervention (PCI) has become widespread, and many registries have reported good results. This study established a new algorithm and applied it to current CTO practice and collected a CTO registry to document the results. It compared the outcomes of a retrograde versus antegrade approach in a contemporary multicentre CTO registry. METHODS: Between 1 January 2016 and 31 December 2016, consecutive patients who underwent CTO PCI performed by eight high-volume CTO operators were included in a registry. RESULTS: During this period, 485 patients with 497 CTOs were treated with technical and procedural success rates of 93.8% and 89.9%, respectively. Antegrade and retrograde technical success was 95.9% and 91.2% (p = 0.03), respectively. Procedural success for antegrade and retrograde was 94.4% and 84.6%, respectively (p < 0.001). The pure retrograde success rate was 80% and pure antegrade success rate was 75%. Technical success in different Japanese Chronic Total Occlusion (JCTO) score groups was 100% (JCTO 0), 96.2% (JCTO 1), 95.3% (JCTO 2), and 92.5% (JCTO ≥ 3), with no statistical difference in success rates between different JCTO scores. In-hospital major adverse cardiac event (MACE) was 3.8% and more common in the retrograde group (6.6% vs 1.5%). CONCLUSIONS: The retrograde approach, when used by experienced operators who have been well trained in retrograde approach, can produce higher retrograde success in complex CTO lesions. The use of an algorithm approach can improve procedural efficiency, reduce contrast and radiation dosage, and reduce the time spent in failure mode. These tools remain vital to the development of future CTO PCI.
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Algoritmos , Oclusión Coronaria/cirugía , Vasos Coronarios/cirugía , Intervención Coronaria Percutánea/métodos , Sistema de Registros , Enfermedad Crónica , Angiografía Coronaria/métodos , Oclusión Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Antegrade dissection reentry with Stingray device (Boston Scientific, Marlborough, MA) accounts for 20-34% of the chronic total occlusion (CTO) cases in the various hybrid operators' CTO registries and is an important component of CTO crossing algorithms. The Stingray device can facilitate antegrade dissection and reentry, however its use is low outside North America and Europe. The Asia Pacific CTO Club along with three experience Stingray operators from the US, Europe and India, created an algorithm guiding use of the CrossBoss and Stingray catheter. This APCTO Stingray algorithm defines when to use the CrossBoss and Stingray device recommending a reduction in CrossBoss use except for in-stent restenosis lesions and immediate transition from knuckle wiring to the Stingray device. When antegrade wiring fails, choice of Stingray-facilitated reentry versus parallel wiring depends on operator experience, device availability, cost concerns, and anatomical factors. When the antegrade wire enters the subintimal space, we recommend using a rotational microcatheter to produce a channel and deliver the Stingray balloon-so called the "bougie technique." We recommend early switch to Stingray rather than persisting with single wire redirection or parallel wire. We recommend choosing a suitable reentry zone based on preprocedural computer tomography or angiogram, routine use of stick and swap, routine use of Subintimal TRAnscatheter Withdrawal (STRAW) through the Stingray balloon, and the multi stick and swap technique. We believe these techniques and algorithm can facilitate incorporation of the Stingray balloon into the practice of CTO interventionists globally.
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Angioplastia Coronaria con Balón/instrumentación , Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Oclusión Coronaria/terapia , Algoritmos , Angioplastia Coronaria con Balón/efectos adversos , Asia , Australia , Cateterismo Cardíaco/efectos adversos , Enfermedad Crónica , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/fisiopatología , Reestenosis Coronaria/etiología , Técnicas de Apoyo para la Decisión , Diseño de Equipo , Humanos , Nueva Zelanda , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: Despite the advances in wire technology and development of algorithm-driven methodology for chronic total occlusion (CTO) intervention, there is a void in the literature about the technical aspects of CTO wiring. The Asia Pacific CTO Club, a group of 10 experienced operators in the Asia Pacific region, has tried to fill this void with this state-of-the-art review on CTO wiring. METHODS: This review explains, for proximal cap puncture: choices of wires, shaping of the wire, use of dual lumen catheter, and method of step-down of wire penetration force for successful wiring. In wiring the CTO body, the techniques of loose tissue tracking, intentional intimal plaque tracking, and intentional subintimal wiring are described in detail. For distal lumen wiring, a blunt distal cap, presence of a distal cap side branch, calcium, and sharp tapered distal stump predict cap toughness, and wire penetration force should be stepped-up in these cases. The importance of choosing between redirection, parallel wiring, and Stingray (Boston Scientific, Marlborough, MA, USA) for angiographic guidance is discussed along with which will be more successful. On the retrograde side, the problems encountered with distal cap puncture and methods to overcome these problems are explained. The method of wiring the CTO body through a retrograde approach depending on the morphology of the CTO is described. Different reverse controlled antegrade and retrograde tracking (CART) wiring methods - including end balloon wiring, side balloon entry, and conventional reverse CART - are explained in detail. CONCLUSION: This is a systematic CTO wiring review, which is believed to be beneficial for CTO operators worldwide.
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Algoritmos , Angioplastia Coronaria con Balón/métodos , Cardiología , Oclusión Coronaria/cirugía , Intervención Coronaria Percutánea/métodos , Sociedades Médicas , Asia/epidemiología , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/epidemiología , Humanos , Incidencia , Islas del Pacífico/epidemiologíaRESUMEN
OBJECTIVE: With the evolution of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) technique and equipment, the success rate of CTO PCI has improved over the years. We examined the failed cases in this expert registry and looked at the mode of failure. METHODS: In 2016, consecutive CTO PCI performed by eight high volume CTO with an agreed CTO algorithm were examined in a registry. RESULTS: There was a total of 485 patients with 497 CTOs were treated with technical and procedural success rates of 93.8% and 89.9%, respectively. The mean J-CTO score was 2.9 ± 1.2. The main mode of failure in cases with only antegrade attempt was inability to wire to true lumen despite advanced antegrade wiring technique for example, parallel wiring or IVUS guided wiring (10 out of 11 cases). The mode of failure in retrograde attempt was: 30% was due to inability to wire the collateral channel; 30% was due to failed reverse controlled antegrade and retrograde subintimal tracking (CART); 30% was due to inability to cross CTO by retrograde microcatheter. Four cases were terminated prematurely due to procedure complications. CONCLUSION: Similar to previous reported studies, primary failure mode of only antegrade attempt was inability to wire to true lumen. However, contrary to other registries where failure to cross the retrograde channel with wire was the predominant failure mode, the retrograde failure mode was equally divided between failure to cross the channel with wire, failure to do reverse CART, and failure to cross the CTO with the microcatheter.
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Algoritmos , Oclusión Coronaria/terapia , Técnicas de Apoyo para la Decisión , Intervención Coronaria Percutánea , Anciano , Asia , Australia , Enfermedad Crónica , Toma de Decisiones Clínicas , Angiografía Coronaria , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Insuficiencia del TratamientoRESUMEN
We present a patient with non-obstructive intraluminal clot protrusion treated with medical therapy. Follow-up OCT scan showed layered neointimal changes similar to images observed in stent failure.
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Trombosis Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Oclusión de Injerto Vascular/diagnóstico , Infarto del Miocardio con Elevación del ST/diagnóstico , Stents/efectos adversos , Trombectomía/métodos , Tomografía de Coherencia Óptica/métodos , Adulto , Trombosis Coronaria/complicaciones , Trombosis Coronaria/cirugía , Humanos , Masculino , Neointima/patología , Infarto del Miocardio con Elevación del ST/etiología , Infarto del Miocardio con Elevación del ST/cirugíaRESUMEN
During recent years, equipment and techniques for percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) have improved significantly. The retrograde approach remains critical to the improved success of CTO PCI. Currently, the reverse controlled antegrade and retrograde tracking (CART) technique has become the dominant retrograde wire crossing technique. In this article, we propose a standardised terminology and classification for this technique divided into three subtypes: a) conventional reverse CART, usually involving the use of large balloons on the antegrade wire to achieve re-entry within the CTO segment; b) "directed" reverse CART, which is characterised by small antegrade balloon size and more active, intentional vessel tracking and penetration with a controllable retrograde wire, still within the CTO segment; and c) "extended" reverse CART, in which the intimal/subintimal dissection is extended proximal or distal to the CTO segment, achieving re-entry outside the CTO segment. The proposed standardised terminology will facilitate the communication, teaching and adoption of the reverse CART techniques.
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Angioplastia Coronaria con Balón , Oclusión Coronaria/cirugía , Intervención Coronaria Percutánea , Angioplastia Coronaria con Balón/métodos , Enfermedad Crónica , Angiografía Coronaria/métodos , Humanos , Intervención Coronaria Percutánea/métodos , Resultado del TratamientoRESUMEN
Retrograde CTO PCI is an effective method to improve the success rate of CTO PCI. Despite several comprehensive and detailed descriptive papers on the retrograde techniques, retrograde CTO PCI remains difficult for many interventionists. We, the Asia Pacific CTO club, propose a new retrograde CTO PCI algorithm, which focuses on three specific problems in the retrograde approach. First, how to overcome the tough proximal cap. Then, how to cross the collateral channels safely and efficiently. Finally, how to cross the CTO and, in particular, the problems of reverse CART. We explain our new philosophy of contemporary reverse CART. We hope that this algorithm will provide the tools for operators to overcome the difficulties of retrograde CTO PCI and that it will become a platform for discussion, training, and proctoring for the retrograde approach.
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When we learn to drive, our driving instructor tells us how to check the side mirror and turn your head to check the blind spot before changing lanes. He tells us how to stop at stop signs, how to drive in slippery conditions, the safe stopping distances, and these all make our driving safe. Similarly, when we learn PCI, our mentors teach us to seat the guiding catheter co-axially, to wire the vessel safely, to deliver balloon and stents over the wire, to watch the pressure of the guiding, in order that we perform PCI safely and evade complications. In retrograde CTO PCI, there is no such published teaching. Also many individual mentors have not had the wide experience to see all the possible complications of retrograde CTO PCI and, therefore, may not be able to warn their apprentice. As the number of retrograde procedures increase worldwide, there is a corresponding increase in catastrophic complications, many of which, we as experts, can see are easily avoidable. To breach this gap in knowledge, this article describes 12 commonly met inherent traps in retrograde CTO PCI. They are inherent because by arranging our equipment in the manner to perform retrograde CTO PCI, these complications are either induced directly or happen easily. We hope this work will enhance safety of retrograde CTO PCI and avoid many catastrophic complications for our readers and operators. © 2017 Wiley Periodicals, Inc.