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Sahu AK, Kazmi DH, Kaushik A. Is it Worthy Enough to Revascularize Chronically Occluded Coronaries? Cardiol Rev 2024; 32:338-347. [PMID: 36912530 DOI: 10.1097/crd.0000000000000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Chronic total occlusions (CTOs) represent the "final frontier" of coronary interventions with the lowest procedural success rates and the most common reason for incomplete revascularization and referral to coronary artery bypass graft surgery (CABG). CTO lesions are not an infrequent finding during coronary angiography. They are often responsible for enhancing the complexity of the coronary disease burden thereby affecting the final interventional decision in the process. Notwithstanding the modest technical success of CTO-PCI, most of the earlier observational data demonstrated a clear survival benefit free of major cardiovascular events (MACE) in patients undergoing successful CTO revascularization. However, data from recent randomized trials fail to uphold the same survival advantage albeit, showing some trend toward improvement in left ventricular function, quality of life indicators and freedom from fatal ventricular arrythmia. Various guidance statements propose a well-defined role for CTO intervention in specific situations provided criterions for patient selection, appreciable inducible ischemia, myocardial viability and cost-risk-benefit analysis are met.
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Affiliation(s)
- Ankit Kumar Sahu
- From the Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
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2
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Xu W, Ma J, Chen Y, Zhou F, Zhou C, Zhang LJ. Coronary chronic total occlusion on coronary CT angiography: what radiologists should know? Insights Imaging 2024; 15:55. [PMID: 38411752 PMCID: PMC10899151 DOI: 10.1186/s13244-024-01621-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/11/2024] [Indexed: 02/28/2024] Open
Abstract
Coronary chronic total occlusion (CTO) often occurs in patients with obstructive coronary artery disease, which remains one of the greatest challenges for interventional cardiologists. Coronary computed tomography angiography (CCTA) with its emerging post-processing techniques can provide a detailed assessment of CTO lesions before percutaneous coronary intervention (PCI), playing an important role in the clinical management of CTO PCI, from early diagnosis, pre-procedural outcome prediction, the crossing algorithm planning, intraprocedural guidance, and finally post-procedural assessment and follow-up. In addition, the feasibility of CT perfusion (CTP) in patients with CTO has been validated. Combined CCTA and CTP have the great potential to be the one-stop-shop imaging modality for assessing both anatomy and function of CTO lesions. This review aims to make radiologists understand the role of CCTA in the diagnosis and assessment of CTO lesions, thus assisting interventionalists in optimizing CTO PCI crossing strategies with the expertise of radiologists.Critical relevance statement The anatomical features of CTO on CCTA can reveal the complexity of CTO lesions and are associated with CTO PCI outcome, thus helping interventionalists optimize CTO PCI crossing strategies.Key points • CTO is the common lesion in invasive coronary angiography, and CTO PCI is technically difficult and its success rate is relatively low.• Length, collaterals, and attenuation-related signs can help distinguish CTO from subtotal occlusion.• The anatomical features of CTO lesions can help grade the difficulty of CTO PCI and predict procedural outcomes and long-term outcomes of CTO PCI.• The real-time fusion of CCTA with fluoroscopic angiography can be applied in highly complicated CTO lesions.• After CTO PCI, CCTA can help guide a second CTO PCI re-entry or follow up stent patency.
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Affiliation(s)
- Wei Xu
- Department of Radiology, Jinling Hospital, Nanjing Medical University, 305 Zhongshan East Road, Nanjing, China
| | - Junfeng Ma
- Emergency Medical Center, Xi'an Xianyang International Airport Co., Ltd., Xianyang, China
| | - Yiwen Chen
- Department of Radiology, Jinling Hospital, Nanjing Medical University, 305 Zhongshan East Road, Nanjing, China
| | - Fan Zhou
- Department of Radiology, Affiliated Jinling Hospital of Medical School, Nanjing University, 305 Zhongshan East Road, Nanjing, China
| | - Changsheng Zhou
- Department of Radiology, Affiliated Jinling Hospital of Medical School, Nanjing University, 305 Zhongshan East Road, Nanjing, China
| | - Long Jiang Zhang
- Department of Radiology, Jinling Hospital, Nanjing Medical University, 305 Zhongshan East Road, Nanjing, China.
- Department of Radiology, Affiliated Jinling Hospital of Medical School, Nanjing University, 305 Zhongshan East Road, Nanjing, China.
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3
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Kokkinidis DG, Schizas D, Pargaonkar S, Karamanis D, Mylonas KS, Hasemaki N, Palaiodimos L, Varrias D, Tzavellas G, Siasos G, Klonaris C, Kharawala A, Chlorogiannis DD, Georgopoulos S, Bakoyiannis C. Differences between Lower Extremity Arterial Occlusion vs. Stenosis and Predictors of Successful Endovascular Interventions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2029. [PMID: 38004078 PMCID: PMC10673017 DOI: 10.3390/medicina59112029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: In patients with peripheral artery disease, there is insufficient understanding of characteristics that predict successful revascularization of the lower extremity (LE) chronic total occlusions (CTOs) and baseline differences in demographic, clinical, and angiographic characteristics in patients with LE CTO vs. non-CTO. We aim to explore these differences and predictors of successful revascularization among CTO patients. Materials and Methods: Two vascular centers enrolled LE-CTO patients who underwent endovascular revascularization. Data on demographics, clinical, angiographic, and interventional characteristics were collected. LE non-CTO arterial stenosis patients were compared. A total of 256 patients with LE revascularization procedures were studied; among them, 120 had CTOs and 136 had LE stenosis but no CTOs. Results: Aspirin use (Odds ratio, OR: 3.43; CI 1.32-8.88; p = 0.011) was a positive predictor whereas a history of malignancy (OR: 0.27; CI 0.09-0.80; p = 0.018) was a negative predictor of successful crossing in the CTO group. The CTO group had a higher history of myocardial infarction (29.2 vs. 18.3%, p = 0.05), end-stage renal disease (19.2 vs. 9.6%, p = 0.03), and chronic limb-threatening ischemia as the reason for revascularization (64.2 vs. 22.8%, p < 0.001). They were more likely to have advanced TransAtlantic Inter-Society Consensus (TASC) stages, multi-vessel revascularization procedures, longer lesions, and urgent treatment. Conclusions: The use of aspirin is a positive predictor whereas a history of malignancy is a negative predictor for successful crossing in CTO lesions. Additionally, LE-CTO patients have a higher incidence of comorbidities, which is expected given their higher disease burden. Successful endovascular re-vascularization can be associated with baseline clinical variables.
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Affiliation(s)
- Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sumant Pargaonkar
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Dimitrios Karamanis
- Department of Economics, University of Piraeus, 18534 Piraeus, Greece
- Department of Health Informatics, Rutgers School of Health Professions, Newark, NJ 07107, USA
| | - Konstantinos S Mylonas
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Natasha Hasemaki
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Dimitrios Varrias
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Georgios Tzavellas
- Department of Vascular Surgery, Ball Memorial Hospital, Muncie, IN 47303, USA
| | - Gerasimos Siasos
- 3rd Department of Cardiology, Sotiria General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Christos Klonaris
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Amrin Kharawala
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY 10461, USA
| | | | - Sotirios Georgopoulos
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Galassi AR, Vadalà G, Maniscalco L, Gasparini G, Jo D, Bozinovic NZ, Gorgulu S, Gehrig T, Grancini L, Ungi I, La Scala E, Ladwiniec A, Stojkovic S, La Manna A, Tumscitz C, Elhadad S, Werner GS, Sianos G, Garbo R, Carlino M, Mashayekhi K, di Mario C. Wire-based antegrade dissection re-entry technique for coronary chronic total occlusions percutaneous revascularization: Experience from the ERCTO Registry. Catheter Cardiovasc Interv 2023; 102:864-877. [PMID: 37668012 DOI: 10.1002/ccd.30827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/26/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND The recent development and widespread adoption of antegrade dissection re-entry (ADR) techniques have been underlined as one of the antegrade strategies in all worldwide CTO consensus documents. However, historical wire-based ADR experience has suffered from disappointing long-term outcomes. AIMS Compare technical success, procedural success, and long-term outcome of patients who underwent wire-based ADR technique versus antegrade wiring (AW). METHODS One thousand seven hundred and ten patients, from the prospective European Registry of Chronic Total Occlusions (ERCTO), underwent 1806 CTO procedures between January 2018 and December 2021, at 13 high-volume ADR centers. Among all 1806 lesions attempted by the antegrade approach, 72% were approached with AW techniques and 28% with wire-based ADR techniques. RESULTS Technical and procedural success rates were lower in wire-based ADR than in AW (90.3% vs. 96.4%, p < 0.001; 87.7% vs. 95.4%, p < 0.001, respectively); however, wire-based ADR was used successfully more often in complex lesions as compared to AW (p = 0.017). Wire-based ADR was used in most cases (85%) after failure of AW or retrograde procedures. At a mean clinical follow-up of 21 ± 15 months, major adverse cardiac and cerebrovascular events (MACCEs) did not differ between AW and wire-based ADR (12% vs. 15.1%, p = 0.106); both AW and wire-based ADR procedures were associated with significant symptom improvements. CONCLUSIONS As compared to AW, wire-based ADR is a reliable and effective strategy successfully used in more complex lesions and often after the failure of other techniques. At long-term follow-up, patient's MACCEs and symptoms improvement were similar in both antegrade techniques.
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Affiliation(s)
- Alfredo R Galassi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Giuseppe Vadalà
- Division of Cardiology, University Hospital "P. Giaccone", Palermo, Italy
| | - Laura Maniscalco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Gabriele Gasparini
- Department of Invasive Cardiology, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Dens Jo
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Sevket Gorgulu
- Cardiology Department, Acıbadem University Medical Faculty, Istanbul, Turkey
| | | | | | - Imre Ungi
- Second Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary
| | | | - Andrew Ladwiniec
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sinisa Stojkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- mDepartment of Cardiology, Clinical Center of Serbia, Beograd, Belgrade, Serbia
| | - Alessio La Manna
- Cardio-Thoracic-Vascular Department, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Carlo Tumscitz
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Ferrara, Italy
| | - Simon Elhadad
- Department of Cardiology, CH Marne La Vallée, Jossigny, France
| | - Gerald S Werner
- Medizinische Klinik I, Klinikum Darmstadt, Darmstadt, Germany
| | - Georgios Sianos
- 1st Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Roberto Garbo
- nterventional Cardiology Department, Maria Pia Hospital, GVM Care and Research, Turin, Italy
| | - Mauro Carlino
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Kambis Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Carlo di Mario
- Department of Clinical & Experimental Medicine, Structural Interventional Cardiology Division, Careggi University Hospital, Florence, Italy
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Yan S, Feng H, Ma L, Xu JC, Han HJ, Huang HE, Tan HQ, Fang C. Predictors of successful endovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion. BMC Neurol 2023; 23:376. [PMID: 37858051 PMCID: PMC10585922 DOI: 10.1186/s12883-023-03424-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Endovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion (ILAO) has been reported to be feasible, but technically challenging. This study aimed to determine the predictors of successful endovascular recanalization in patients with symptomatic nonacute ILAO. METHODS The outcomes of endovascular recanalization attempts performed in 70 consecutive patients showing symptomatic nonacute ILAO with hemodynamic cerebral ischemia between January 2016 to December 2022 were reviewed. Potential variables, including clinical and radiological characteristics related to technical success, were collected. Univariate analysis and multivariate logistic regression were performed to identify predictors of successful recanalization for nonacute ILAO. RESULTS Technically successful recanalization was achieved in 57 patients (81.4%). The periprocedural complication rate was 21.4% (15 of 70), and the overall 30-day morbidity and mortality rates were 7.1% (5 of 70) and 2.9% (2 of 70), respectively. Univariate analysis showed that successful recanalization was associated with occlusion duration, stump morphology, occlusion length, slow distal antegrade flow sign, and the presence of bridging collateral vessels. Multivariate analysis showed that occlusion duration ≤ 3 months (odds ratio [OR]: 22.529; 95% confidence interval [CI]: 1.636-310.141), tapered stump (OR: 7.498; 95% CI: 1.533-36.671), and occlusion length < 10 mm (OR: 7.049; 95% CI: 1.402-35.441) were independent predictive factors for technical success of recanalization. CONCLUSIONS Occlusion duration ≤ 3 months, tapered stump, and occlusion length < 10 mm were independent positive predictors of technical success of endovascular recanalization for symptomatic nonacute ILAO. These findings may help predict the likelihood of successful recanalization in patients with symptomatic nonacute ILAO and also provide a reference for the selection of appropriate patients. Further prospective and multicenter studies are required to validate our findings.
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Affiliation(s)
- Shuo Yan
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Hao Feng
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Lin Ma
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Ji-Chong Xu
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Hong-Jie Han
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Hong-En Huang
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Hua-Qiao Tan
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China.
| | - Chun Fang
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
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Wu X, Wu M, Huang H, Liu Z, Cai J, Zhang Q, Huang H. Antegrade versus Retrograde Approach for Recanalization of Ostial or Stumpless Coronary Chronic Total Occlusion. Int J Gen Med 2023; 16:3995-4005. [PMID: 37674582 PMCID: PMC10479831 DOI: 10.2147/ijgm.s429956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023] Open
Abstract
Purpose This research aimed to evaluate the procedural and in-hospital clinical outcomes of percutaneous coronary intervention (PCI) for ostial or stumpless chronic total occlusion (CTO) utilizing both the antegrade-only and retrograde approaches. Methods A comprehensive retrospective examination was conducted on the procedural and in-hospital clinical outcomes of 89 consecutive patients subjected to ostial or stumpless CTO PCI at our institution between April 2015 and October 2022. Results The antegrade-only technique demonstrated a superior technical success rate (92.0% vs 71.9%, p = 0.041) and procedural success rate (92.0% vs 68.8%, p = 0.022) in comparison to the retrograde approach (RA). The RA group presented a notably elevated Japanese-CTO (J-CTO) score relative to the antegrade-only approach group (2.45±0.73 vs 1.64±0.70, p < 0.001). The antegrade-only approach group manifested an increased frequency of microchannels at the proximal stump relative to the RA group (56.0% vs 10.9%, p < 0.001). In-hospital major adverse cardiac events (MACE) and in-hospital myocardial infarction (MI) were observed more prevalently in the RA group (18.8% vs 0, p = 0.003; 15.6% vs 0, p = 0.008; respectively). A J-CTO score below 2 and the manifestation of microchannels at the proximal stump were identified as predictors for successful antegrade-only approach PCI for ostial or stumpless CTO (OR: 2.79 [95% CI: 1.92-5.03, P =0.003]; OR: 2.89 [95% CI: 1.32-6.03, P =0.001]; respectively). Conclusion Relative to RA PCI for ostial or stumpless CTO, the antegrade-only approach is utilized for less complex CTO lesions and is associated with a diminished probability of in-hospital MACE.
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Affiliation(s)
- Xi Wu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, 411100, People’s Republic of China
| | - Mingxing Wu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, 411100, People’s Republic of China
| | - Haobo Huang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, 411100, People’s Republic of China
| | - Zhe Liu
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, 411100, People’s Republic of China
| | - Jie Cai
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, 411100, People’s Republic of China
| | - Qizhou Zhang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, 411100, People’s Republic of China
| | - He Huang
- Department of Cardiology, Xiangtan Central Hospital, Xiangtan, Hunan, 411100, People’s Republic of China
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Fukuizumi I, Tokita Y, Shiomura R, Noma S, Matsuda J, Sangen H, Kubota Y, Komiyama H, Nakata J, Miyachi H, Tara S, Shimizu W, Yamamoto T, Takano H. Angioscopic findings 1 year after percutaneous coronary intervention for chronic total occlusion. J Cardiol 2023; 81:91-96. [PMID: 36057486 DOI: 10.1016/j.jjcc.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/02/2022] [Accepted: 08/09/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Chronic total occlusion (CTO) is a high-risk factor for stent thrombosis, but little is known about the difference in neointimal healing between CTO and non-CTO lesions regarding implanted stents. We investigated factors affecting neointimal healing after stent implantation for CTO and non-CTO lesions using angioscopy. METHODS We retrospectively evaluated 106 stents in 85 consecutive patients between March 2016 and July 2020. Their average age was 68 ± 11 years, and participants (73 male and 12 female) underwent follow-up angiography and angioscopy 1 year after percutaneous coronary intervention (PCI). The stents (n = 106) were divided into three groups according to the lesion status at the previous PCI: CTO (n = 17), acute coronary syndrome (ACS) (n = 35), and stable coronary artery disease without CTO or non-CTO (n = 54). RESULTS The neointimal stent coverage grade was significantly lower in the CTO and ACS groups than in the non-CTO group (0.4 ± 0.5, 0.9 ± 0.8, and 1.4 ± 0.8, respectively, p < 0.001). Thrombi were significantly more frequent in CTO and ACS than in non-CTO (71 %, 51 %, and 15 %, respectively, p < 0.001). The yellow grade in CTO was comparable to that in ACS but significantly higher in CTO than in non-CTO (CTO vs. ACS vs. non-CTO 1.5 ± 0.7, 1.4 ± 0.6, and 0.9 ± 0.7, respectively, p = 0.007). CONCLUSIONS Delayed healing occurs in stents implanted for CTO lesions. Longer dual-antithrombotic therapy may be beneficial.
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Affiliation(s)
- Isamu Fukuizumi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Yukichi Tokita
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan.
| | - Reiko Shiomura
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Satsuki Noma
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Junya Matsuda
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hideto Sangen
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshiaki Kubota
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hidenori Komiyama
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Jun Nakata
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hideki Miyachi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Shuhei Tara
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Takeshi Yamamoto
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hitoshi Takano
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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Liao R, Li Z, Wang Q, Lin H, Sun H. Revascularization of chronic total occlusion coronary artery and cardiac regeneration. Front Cardiovasc Med 2022; 9:940808. [PMID: 36093131 PMCID: PMC9455703 DOI: 10.3389/fcvm.2022.940808] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
Coronary chronic total occlusion (CTO) contributes to the progression of heart failure in patients with ischemic cardiomyopathy. Randomized controlled trials demonstrated that percutaneous coronary intervention (PCI) for CTO significantly improves angina symptoms and quality of life but fails to reduce clinical events compared with optimal medical therapy. Even so, intervening physicians strongly support CTO-PCI. Cardiac regeneration therapy after CTO-PCI should be a promising approach to improving the prognosis of ischemic cardiomyopathy. However, the relationship between CTO revascularization and cardiac regeneration has rarely been studied, and experimental studies on cardiac regeneration usually employ rodent models with permanent ligation of the coronary artery rather than reopening of the occlusive artery. Limited early-stage clinical trials demonstrated that cell therapy for cardiac regeneration in ischemic cardiomyopathy reduces scar size, reverses cardiac remodeling, and promotes angiogenesis. This review focuses on the status quo of CTO-PCI in ischemic cardiomyopathy and the clinical prospect of cardiac regeneration in this setting.
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Affiliation(s)
- Ruoxi Liao
- Department of Clinical Medicine, Dalian Medical University, Dalian, China
| | - Zhihong Li
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiancheng Wang
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hairuo Lin
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- *Correspondence: Hairuo Lin, ,
| | - Huijun Sun
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
- Huijun Sun,
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Fujihara M, Kurata N, Yazu Y, Mori S, Tomoi Y, Horie K, Nakama T, Tsujimura T, Nakata A, Iida O, Sonoda S, Torii S, Ishihara T, Azuma N, Urasawa K, Ohki T, Komori K, Kichikawa K, Yokoi H, Nakamura M. Clinical expert consensus document on standards for lower extremity artery disease of imaging modality from the Japan Endovascular Treatment Conference. Cardiovasc Interv Ther 2022; 37:597-612. [DOI: 10.1007/s12928-022-00875-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
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10
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Werner GS, Brilakis ES. Chronic Total Coronary Occlusion. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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11
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Wang R, He Y, Xing H, Zhang D, Tian J, Le Y, Zhang L, Chen H, Song X, Wang Z. Inclusion of quantitative high-density plaque in coronary computed tomographic score system to predict the time of guidewire crossing chronic total occlusion. Eur Radiol 2022; 32:4565-4573. [PMID: 35182204 PMCID: PMC9213281 DOI: 10.1007/s00330-022-08564-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/01/2021] [Accepted: 01/04/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to establish a new scoring system that includes histological quantitative features derived from coronary computed tomographic angiography (CCTA) to predict the efficiency of chronic total occlusion percutaneous coronary intervention (CTO-PCI). METHODS This study analyzed clinical, morphological, and histological characteristics of 207 CTO lesions in 201 patients (mean age 60.0 [52.0-65.0] years, 85% male), which were recruited from two centers. The primary endpoint was a guidewire successfully crossing the lesions within 30 m. The new predictive model was generated by factors that were determined by multivariate analysis. The CCTA plaque (CTAP) score that included a quantitative plaque characteristic was developed by assigning an appropriate integer score to each independent predictor, then summing all points. In addition, the CTAP score was compared with other predictive scores based on CCTA. RESULTS The endpoint was achieved in 63% of the lesions. The independent predictors included previous CTO-PCI failure, the proximal blunt stump, proximal side branch, distal side branch, occluded segment bending > 45°, and high-density plaque volume (fibrous volume + calcified volume) ≥ 19.9 mm3. As the score increased from 0 to 5, the success rate of the guidewire crossing within 30 m decreased from 96 to 0%. Comparing the CTAP score with other predictive scores, the CTAP score showed the highest discriminant power (c-statistic = 0.81 versus 0.73-0.77, p value 0.02-0.07). The CTAP score showed similar results for procedural success. CONCLUSION The CTAP score efficiently predicted the guidewire crossing efficiency and procedural success. KEY POINTS • An increase in high-density plaque volume (fibrous + dense calcium) was more probable to reduce the efficiency of crossing and lead to procedural failure. • The new prediction scoring system with the addition of the quantitative characteristics of plaques had an improved predictive ability compared with the traditional prediction scoring system.
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Affiliation(s)
- Rui Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Road, Xicheng District, Beijing, 100050, China
- Department of Radiology, Affiliated Hospital, Chengde Medical University, Chengde, Hebei, China
| | - Yi He
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Road, Xicheng District, Beijing, 100050, China
| | - Haoran Xing
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Dongfeng Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Jinfan Tian
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China
| | - Yinghui Le
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Road, Xicheng District, Beijing, 100050, China
| | - Lijun Zhang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiantao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
- Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China.
- Beijing Lab for Cardiovascular Precision Medicine, Beijing, China.
| | - Zhenchang Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong An Road, Xicheng District, Beijing, 100050, China.
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12
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Rahman MS, de Winter R, Nap A, Knaapen P. Advances in the Post-coronary Artery Bypass Graft Management of Occlusive Coronary Artery Disease. Interv Cardiol 2021; 16:e33. [PMID: 35106069 PMCID: PMC8785096 DOI: 10.15420/icr.2021.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/07/2021] [Indexed: 11/04/2022] Open
Abstract
Revascularisation of chronic total occlusion (CTO) represents one of the most challenging aspects of percutaneous coronary intervention, but advances in equipment and an understanding of CTO revascularisation techniques have resulted in considerable improvements in success rates. In patients with prior coronary artery bypass grafting (CABG) surgery, additional challenges are encountered. This article specifically explores these challenges, as well as antegrade methods of CTO crossing. Techniques, equipment that can be used and reference texts are highlighted with the aim of providing potential CTO operators adequate information to tackle additional complexities likely to be encountered in this cohort of patients. This review forms part of a wider series where additional aspects of patients with prior CABG should be factored into decisions and methods of revascularisation.
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Affiliation(s)
| | - Ruben de Winter
- Department of Cardiology, Amsterdam Medical Centre, VU Medical Centre, Amsterdam, the Netherlands
| | - Alex Nap
- Department of Cardiology, Amsterdam Medical Centre, VU Medical Centre, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam Medical Centre, VU Medical Centre, Amsterdam, the Netherlands
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13
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Zografos T, Tsiafoutis I, Tsoumeleas A, Floropoulou C, Gkini C, Koutouzis M. Chronic Total Occlusion PCI Techniques in 2020. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00914-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Kadoya Y, Zen K, Iida O, Yamamoto Y, Kawasaki D, Yamauchi Y, Shintani Y, Sugano T, Yokoi H, Matoba S, Nakamura M. Thrombotic Lesions are Associated with Poor Outcomes after Endovascular Treatment in Patients with Non-Acute Aortoiliac Total Occlusions. J Atheroscler Thromb 2021; 28:1323-1332. [PMID: 33563884 PMCID: PMC8629701 DOI: 10.5551/jat.61150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aim: The post-endovascular treatment outcomes of thrombotic lesions remain unclear. This study aimed to investigate the effects of thrombotic lesions on post-endovascular treatment outcomes in patients with non-acute aortoiliac total occlusions. Methods: This subanalysis of a multicenter prospective observational registry study included patients from 64 institutions in Japan between April 2014 and April 2016. A total of 346 patients (394 limbs; median age, 72 years), including 186 men, underwent endovascular treatment for non-acute aortoiliac total occlusions and were included. The patients were classified as having thrombotic or non-thrombotic lesions. The primary (1-year primary patency rate) and secondary (1-year overall survival rate) endpoints were evaluated. Results: Thrombotic lesions were identified in 18.5% (64/346) of the patients. The 1-year primary patency (85.9% versus 95.4%, log-rank
p
<.001) and overall survival (90.6% versus 97.9%, log-rank
p
=.003) rates were significantly lower in the thrombotic group than in the non-thrombotic group. Thrombotic lesions had significant effects on the post-endovascular treatment outcomes, with adjusted hazard ratios of 3.91 (95% confidence interval, 1.64–9.34,
p
=.002) for primary patency and 4.93 (95% confidence interval, 1.59–15.3,
p
=.006) for all-cause mortality.
Conclusions: Thrombotic lesions were associated with 1-year restenosis and all-cause mortality after endovascular treatment for non-acute aortoiliac total occlusions. Endovascular treatment strategies should be carefully planned for patients with thrombotic lesions.
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Affiliation(s)
- Yoshito Kadoya
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Osamu Iida
- Cardiovascular Centre, Kansai Rosai Hospital
| | - Yoshito Yamamoto
- Department of Cardiovascular Medicine, Iwaki Kyoritsu General Hospital
| | | | | | | | - Teruyasu Sugano
- Department of Cardiovascular Medicine, Yokohama City University Hospital
| | | | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University, Ohashi Medical Centre
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15
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Allan RB, Delaney CL. Identification of micro-channels within chronic total occlusions using contrast-enhanced ultrasound. J Vasc Surg 2021; 74:606-614.e1. [PMID: 33548424 DOI: 10.1016/j.jvs.2020.12.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Vascular micro-channels within chronic total occlusions (CTO) have been identified in histopathology and animal studies. They have been proposed as a potential path for achieving endovascular crossing via the lumen. There are currently no noninvasive means of imaging these structures. The aim of this study was to investigate whether contrast-enhanced ultrasound (CEUS) examination can identify micro-channels within CTO in humans. METHODS CTO within the femoropopliteal arteries were imaged with CEUS examination in 38 patients. Segments containing micro-channels were identified and their length measured. The proportion of occlusion length containing micro-channels was assessed for each case. Micro-channel appearances including linear or tortuous configuration, crossing of occlusion caps, and connections to vasa vasorum were recorded. RESULTS The median CTO length was 17.0 cm (interquartile range [IQR], 6.9-27.9 cm) and median age of CTO was 12 months (IQR, 6-16 months). Micro-channels were identified in 92.1% of cases (35/38). The median length within a lesion containing micro-channels was 6.4 cm (IQR, 2.4-14.3 cm) and median proportion of CTO containing micro-channels was 47.9% (IQR, 1.7%-28.5%). A linear micro-channel configuration was seen in 84.2% of cases and a tortuous configuration was seen in 57.9% of cases. Micro-channel connections through the cap were seen in 50% (19/38 cases) and connections to the vasa vasorum in 71.1% (27/38 cases). No association was found between the proportion of each lesion containing micro-channels and CTO age, lesion length or calcification severity. There were no adverse effects related to contrast use. CONCLUSIONS CEUS can be used to detect micro-channels in CTO in human femoropopliteal arteries. This imaging technique is safe and minimally invasive and may represent a practical method for selection of occlusion crossing method. Further work is required to determine whether identification of micro-channels can be used to improve treatment decision-making and provide a better understanding of the natural history of femoropopliteal CTO.
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Affiliation(s)
- Richard B Allan
- Department of Vascular and Endovascular Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.
| | - Christopher L Delaney
- Department of Vascular and Endovascular Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia; College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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16
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Qureshi WT, Ogunsua AA, Kundu A, Sattar Y, Fisher DZ, Kakouros N. Angled Microcatheter Assisted Antegrade Dissection Re-Entry Technique for Tortuous Totally Occluded Coronary Arteries. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 28S:127-131. [PMID: 33500228 DOI: 10.1016/j.carrev.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/02/2021] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Subacute total occlusion in the setting of a tortuous vessel can be a therapeutic challenge. we demonstrate a safe and successful approach to deploy drug eluting stent of this complex lesion by using angled microcatheter. CASE PRESENTATION A 61-year-old male with multiple atherosclerotic risk factors diagnosed with NSTEMI secondary to subacute total occlusion of the mid right coronary artery (RCA) with collaterals filling from septal perforators arising from mid left anterior descending artery. Due to severe tortuosity of RCA, the wire inside of Corsair microcatheter kept directing away from the lumen. Therefore, Corsair was exchanged for 90-degree SuperCross™ angled microcatheter that was rotated to direct its opening towards the lumen. A Confianza pro 12 wire was used to puncture into the lumen from the subinitimal position. SuperCross™ microcatheter was advanced over the wire into the lumen and eventually drug eluting stents were deployed successfully. CONCLUSION While facing subacute total occlusion with proximal end in a tortuous artery, SuperCross™ microcatheter assisted dissection reentry could be attempted after failure of antegrade wire escalation technique. LEARNING OBJECTIVE Facilitate the use of SuperCross™ microcatheter assisted dissection reentry as a successful approach for subacute total occlusion in tortuous vessels.
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Affiliation(s)
- Waqas T Qureshi
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Adedotun Anthony Ogunsua
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Amartya Kundu
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Yasar Sattar
- Division of Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital, New York, USA
| | - Daniel Z Fisher
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Nikolaos Kakouros
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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17
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Lee JY, Oh YW, Lim DS, Yu CW, Park JH, Joo HJ, Yong HS, Kang EY, Kim C, Lee KY, Hwang SH. Relationship between Coronary Iodine Concentration Determined Using Spectral CT and the Outcome of Percutaneous Coronary Intervention in Patients with Chronic Total Occlusion. Radiol Cardiothorac Imaging 2020; 2:e190203. [PMID: 33778600 PMCID: PMC7977875 DOI: 10.1148/ryct.2020190203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 03/06/2020] [Accepted: 04/13/2020] [Indexed: 05/19/2023]
Abstract
PURPOSE To evaluate the feasibility of coronary iodine concentration (CIC) by using spectral CT in the assessment of the outcome of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). MATERIALS AND METHODS In total, 50 consecutive patients underwent preprocedural coronary CT angiography with spectral CT prior to their staged PCI for CTO between June 2017 and July 2018. Iodine density maps, referred to as iodine-no-water maps throughout, with spectral CT provided the CIC at proximal CTO (CTO-CIC). Depending on the outcome of PCI, all CTO lesions were divided into two groups: failed PCI and successful PCI. The receiver operating characteristic curve was used to determine the cutoff values of CTO-CIC in the assessment of the outcome of PCI for CTO. RESULTS Of the 50 CTO lesions in 50 patients, 34 (68%) and 16 (32%) were assigned to the successful PCI and failed PCI groups, respectively. The mean CTO-CIC was significantly less in the failed PCI group than in the successful PCI group (1.3 mg/mL ± 0.9 [standard deviation] vs 5.2 mg/mL ± 2.5; P < .001). A low CTO-CIC (≤ 2.5 mg/mL) predicted failed PCI with 87% sensitivity, 79% specificity, 79% positive predictive value, and 90% negative predictive value. At multivariable analysis, the low CTO-CIC was significantly associated with the failed PCI (odds ratio, 27.0; 95% confidence interval: 4.9, 147.6; P < .0001). CONCLUSION The CTO-CIC determined by using spectral CT may be useful in the assessment of the outcome of staged PCI for CTO.See also the commentary by Rubinshtein and Blankstein in this issue.© RSNA, 2020.
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18
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Pedersoli F, Zimmermann M, Schulze-Hagen M, Sieben P, Barzakova E, Goerg F, Keil S, Gombert A, Kuhl CK, Isfort P, Bruners P. Retrograde Recanalization of the Celiac Artery via the Pancreaticoduodenal Arcade as a Safe and Valid Alternative to Antegrade Access. Vasc Endovascular Surg 2020; 54:477-481. [PMID: 32419653 DOI: 10.1177/1538574420927132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The antegrade recanalization of an occlusion or high-grade stenosis of the celiac artery via the aorta often represents a technical challenge. A retrograde approach via the superior mesenteric artery and the pancreaticoduodenal arcade may be an alternative approach. Based on our experience, we assess the technical success and the short- and mid-term outcomes of this bailout procedure. METHODS We performed a retrospective analysis of all consecutive patients who underwent recanalization and stent implantation in the celiac artery between January 2010 and December 2018. Data on vascular access, the materials used including stents, as well as the length of the intervention, radiation exposure, and follow-up were assessed. RESULTS Recanalization in combination with stent implantation into the celiac artery was performed in 43 patients. In 39 (91%) of 43 patients, the recanalization was successful with an antegrade approach via the aorta, whereas in 4 (9%) of 43 patients the passage of the stenosis was possible only through a retrograde approach through the superior mesenteric artery and the pancreaticoduodenal arcade followed be advancement of the microwire through the celiac artery into the aorta. The tip of the microwire was captured in the aorta with a snare and pulled out in the femoral introducer sheath and used as a guide for the antegrade implantation of a balloon-expandable stent. CONCLUSIONS The retrograde recanalization of the celiac artery via the pancreaticoduodenal arcade may be technically challenging yet represents a feasible alternative in case of a failed antegrade approach.
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Affiliation(s)
- Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Paul Sieben
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Emona Barzakova
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Fabian Goerg
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Sebastian Keil
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Alexander Gombert
- Clinic for Vascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, RWTH University Hospital Aachen, Aachen, Germany
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19
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Kim K, Lim C, Kim G, Chung JH, Cho YS, Cho JH, Seo JB, Chung WY, Oh SJ, Choi JS, Kim JS, Park JJ, Suh JW, Youn TJ, Chae IH, Choi DJ. Association of Plasma Marker of Oxidized Lipid with Histologic Plaque Instability in Patients with Peripheral Artery Disease. Ann Vasc Surg 2019; 66:554-565. [PMID: 31706994 DOI: 10.1016/j.avsg.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/05/2019] [Accepted: 11/01/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND The association between oxidized low-density lipoprotein (OxLDL) and plaque instability in coronary and carotid artery disease is well established. However, the association between OxLDL and the histologic changes of plaque in peripheral artery disease has not been clearly elucidated. This study aims to investigate the association between plasma OxLDL and histologic plaque instability in patients with peripheral artery disease. METHODS Prospectively obtained plaques from 48 patients who underwent endovascular atherectomy (n = 20), surgical endarterectomy (n = 9), or bypass surgery (n = 19) for treatment of atherosclerotic femoropopliteal artery disease were evaluated for histologic fibrosis, sclerosis, calcification, necrosis, cholesterol cleft, and foamy macrophages using hematoxylin and eosin, oil red O, and immunohistochemical staining. Unstable plaques were defined as plaques that were positive for foamy macrophages and with lipid content of more than 10% of the total plaque area. Plasma OxLDL levels were measured using an enzyme-linked immunosorbent assay (Mercodia AB, Uppsala, Sweden). RESULTS Of the 48 patients, 26 (54%) had unstable plaques. The unstable plaque group was younger, had fewer angiographic total occlusions, less calcification, and more CD68-positive and LOX-1-positive cells than the stable plaque group. Plasma OxLDL levels were significantly higher in the unstable plaque group than in the stable plaque group (57.4 ± 13.9 vs. 47.2 ± 13.6 U/L, P = 0.014). Multivariate analysis revealed that plasma OxLDL level, smoking, angiographic nontotal occlusion, and statin nonuse were independent predictors of unstable plaque. CONCLUSIONS Among patients with peripheral artery disease, the histologic instability of femoropopliteal plaque was independently associated with high plasma OxLDL, smoking, nontotal occlusion, and statin nonuse. Further large-scale studies are necessary to evaluate the role of noninvasive OxLDL measurement for predicting plaque instability and future adverse vascular event.
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Affiliation(s)
- Kichun Kim
- The Armed Forces Medical Command, Seongnam, South Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Gilhyang Kim
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin-Haeng Chung
- Department of Pathology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Young-Seok Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Jun Hwan Cho
- Department of Internal Medicine, Chung-Ang University Hospital, Seoul, South Korea
| | - Jae-Bin Seo
- Department of Internal Medicine, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Woo-Young Chung
- Department of Internal Medicine, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Se-Jin Oh
- Department of Cardiothoracic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jae-Sung Choi
- Department of Cardiothoracic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Jun-Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin Joo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jung-Won Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Tae-Jin Youn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ho Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong-Ju Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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20
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Levesque S, Gamet A, Lattuca B, Lemoine J, Bressollette E, Avran A, Motreff P, Boudou N, Faurie B, Christiaens L. Post-stEnting assessment of Re-endothelialization with optical Frequency domain imaging aftEr Chronic Total Occlusion procedure: The PERFE-CTO Study Design and Rationale. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:760-764. [PMID: 31679911 DOI: 10.1016/j.carrev.2019.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/07/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The treatment of chronic total occlusion of coronary arteries by percutaneous coronary intervention (CTO PCI) is one of the most representative technical advances in ischemic cardiomyopathy of last decade. However, how the complex histopathological remodeling and the new techniques affect healing processes after stent implantation remains unknown. OBJECTIVE The objective of the PERFE-CTO study is to analyze stent coverage, malapposition and other mechanical abnormalities 3 months after CTO recanalization using intravascular imaging. METHODS In a French prospective interventional multicenter study, stent strut coverage, acquired malapposition and neointimal hyperplasia (NIH) proliferation will be systematically assessed with 3 months angiogram control and intracoronary optical frequency domain imaging (OFDI) after successful CTO PCI of >20 mm in length. The impact of routine systematical intracoronary imaging after these complex procedures will also be evaluated by measuring the rate of significant mechanical abnormalities (strut malapposition, edge dissection, thrombus) that was undetected by fluoroscopy alone and by complementary PCI when needed. Secondarily, these data will be compared according to clinical characteristics, antiplatelet therapy use or desobstruction technique (antegrade vs. retrograde, true lumen vs. subintima). Each patient will undergo a one-year clinical follow-up. A total of 150 analyzed CTO lesions is expected. CONCLUSION The PERFE-CTO study will provide essential understanding of the early history after CTO recanalization and the identification of inadequate evolution (stent thrombosis, restenosis or late delayed stent endothelization and cardiovascular outcomes) using intravascular imaging to improve long-term CTO results.
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Affiliation(s)
- Sébastien Levesque
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France.
| | - Alexandre Gamet
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Benoit Lattuca
- Department of Cardiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Julien Lemoine
- Department of Cardiology, Clinique Louis Pasteur, Nancy, France
| | | | - Alexandre Avran
- Department of Cardiology, Institut Arnaud Tzanck, Saint Laurent du Var, France
| | - Pascal Motreff
- Department of Cardiology, Centre Hospitalier Universitaire de Clermont-Ferrand, France
| | - Nicolas Boudou
- Department of Cardiology, Centre Hospitalier Universitaire Rangueil, Toulouse, France
| | - Benjamin Faurie
- Department of Cardiology, Groupe Hospitalier Mutualiste, Grenoble, France
| | - Luc Christiaens
- Department of Cardiology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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21
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Iannaccone G, Scarparo P, Wilschut J, Daemen J, Den Dekker W, De Jaegere P, Zijlstra F, Van Mieghem NM, Diletti R. Current approaches for treatment of coronary chronic occlusions. Expert Rev Med Devices 2019; 16:941-954. [PMID: 31594416 DOI: 10.1080/17434440.2019.1676729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Coronary chronic total occlusions (CTO) represent a challenging subset in interventional cardiology.Areas covered: During the last decade, improvements in materials, techniques, and meticulous pre-procedural lesion assessment have increased the success rate in CTO lesions. Several scores have been developed to address overall lesion evaluation and help select the most appropriate treatment strategy. In addition, specific algorithms such as the hybrid algorithm have been introduced to provide a framework for CTO operators and a rapid management of the various challenging aspects of the procedure. The hybrid approach requires operator's ability to switch from one treatment strategy to another when the first one appears to be unsuccessful. Adequate training and operators' experience remain crucial to improve the likelihood of success.Expert opinion: The aim of this review is to provide insights and guidance for operators on current approaches for treatment of CTO and complication management.
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Affiliation(s)
- Giulia Iannaccone
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Paola Scarparo
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Jeroen Wilschut
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Wijnand Den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Peter De Jaegere
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
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22
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Wang QC, Lin HR, Han Y, Dong H, Xu K, Guan SY, Chen ZH, Hao HX, Bin JP, Liao YL, Jing QM. Optimal use of fielder XT guidewire enhances the success rate of chronic total occlusion percutaneous coronary intervention. World J Clin Cases 2019; 7:928-939. [PMID: 31119138 PMCID: PMC6509270 DOI: 10.12998/wjcc.v7.i8.928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/22/2019] [Accepted: 04/09/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chronic total occlusion (CTO) is found in 18-31% of patients who undergo coronary angiography. Successful recanalization of CTOs is associated with reduced recurrent angina pectoris rates and increased long-term survival. Although the success rate of CTO percutaneous coronary intervention (CTO-PCI) has improved, CTO-PCI remains technically challenging. The Fielder XT guidewire was designed for CTO lesions. To validate whether the use of the guidewire increases the success rate, we compared the results of CTO-PCI with or without the guidewire. We hypothesized that the use of Fielder XT guidewire can increase the success rate of CTO-PCI.
AIM To investigate whether the use of Fielder XT guidewire increases the final procedural success of CTO-PCI via the anterograde approach.
METHODS Between January 2013 and December 2015, a retrospective study was conducted on 1230 consecutive patients with CTO who received PCI via the anterograde approach at the General Hospital of Northern Theater Command. The patients were divided into an XT Group (n = 686) and a no-XT Group (n = 544) depending on whether Fielder XT guidewire was used. Both groups were compared for clinical parameters, lesion-related characteristics, procedural outcomes and in-hospital complications. The data were statistically analyzed using Pearson’s χ2 test for categorical variables, and Students’ t test was used to compare the quantitative data. Significant independent factors and a risk ratio with 95% confidence interval (CI) were assessed by multivariate logistic regression analysis.
RESULTS In total, 1230 patients were recruited; 75.4% of the patients were male, and 55.8% of the patients were in the XT group. The overall success rate was 83.9%, with 87.8% in the XT group. Based on multivariate logistic regression analysis, factors positively associated with procedural success were the use of Fielder XT guidewire (P = 0.005, 95%CI: 1.172-2.380) and systolic blood pressure (P = 0.011, 95%CI: 1.003-1.022), while factors negatively associated with procedural success were blunt stump (P = 0.013, 95%CI: 1.341-11.862), male sex (P = 0.016, 95%CI: 0.363-0.902), New York Heart Association (NYHA) class (P = 0.035, 95%CI: 0.553-0.979), contrast amount (P = 0.018, 95%CI: 0.983-0.998) and occlusion time (P = 0.009, 95%CI: 0.994-0.999). No significant differences were found between the XT group and the no-XT group with respect to clinical parameters, lesion-related characteristics, coronary artery rupture [3 (0.4%) vs 8 (1.5%), P = 0.056], in-hospital death [2 (0.3%) vs 6 (1.1%), P = 0.079] or in-hospital target lesion revascularization [3 (0.4%) vs 7 (1.3%), P < 0.099]. However, there were significant differences between the groups with respect to success rate [602 (87.8%) vs 430 (79.0%), P < 0.001], procedure time [(74 ± 23) vs (83 ± 21), P < 0.001], stent length [(32.0 ± 15.8) vs (37.3 ± 17.6), P < 0.001], contrast amount [(148 ± 46) vs (166 ± 43), P < 0.001], post-PCI myocardial infarction [43 (6.3%) vs 59 (10.8%), P = 0.004], major adverse cardiovascular event [44 (6.4%) vs 57 (10.7%), P = 0.007], side branch loss [31 (4.5%) vs 44 (8.1%), P = 0.009], contrast-induced nephropathy [29 (4.2%) vs 40 (7.4%), P = 0.018] and no reflow [8 (1.2%) vs 14 (2.9%), P = 0.034].
CONCLUSION The use of Fielder XT guidewire shortens the Procedure and increases the success rate of CTO-PCI, and is also associated with reduced complication rates.
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Affiliation(s)
- Qian-Cheng Wang
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
| | - Hai-Ruo Lin
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Yuan Han
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Hai Dong
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
| | - Kai Xu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
| | - Shao-Yi Guan
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
| | - Zhen-Huan Chen
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Hui-Xin Hao
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Jian-Ping Bin
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Yu-Lin Liao
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
| | - Quan-Min Jing
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
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23
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Animal chronic total occlusion models: A review of the current literature and future goals. Thromb Res 2019; 177:83-90. [PMID: 30856383 DOI: 10.1016/j.thromres.2019.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 02/01/2019] [Accepted: 03/04/2019] [Indexed: 12/16/2022]
Abstract
Coronary chronic total occlusions (CTOs) are commonly found in patients undergoing coronary angiography and is associated with poorer prognosis than in those patients with other forms of stable coronary artery disease. As such, with an increasing appreciation of this clinical entity, there is a need to identify, firstly the pathophysiological process driving its formation, as well as new percutaneous strategies for revascularisation with long term durability and improved outcomes. An appropriate, reliable and reproducible animal model is vital for both of these objectives. We review the prevalence of spontaneous collaterals in different species, as well as review the current literature with respect to animal models of CTOs, and compare and contrast the advantages and disadvantages of these differing models. Whilst both extrinsic compression models and endoluminal procedures may create situations analogous to a CTO in a human, the ideal animal model of a CTO will include an occluded artery, functional collaterals and a viable myocardium. This would allow study of the process driving collateral formation and arteriogenesis as well as percutaneous intervention strategies for both acute and long term benefits.
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24
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Ybarra LF, Cantarelli MJC, Lemke VMG, Quadros ASD. Percutaneous Coronary Intervention in Chronic Total Occlusion. Arq Bras Cardiol 2018; 110:476-483. [PMID: 29898046 PMCID: PMC5967142 DOI: 10.5935/abc.20180077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/07/2018] [Indexed: 01/04/2023] Open
Abstract
Percutaneous coronary intervention in chronic total occlusion is a rapidly
evolving area, being considered the last frontier of interventional cardiology.
In recent years, the development of new techniques and equipment, as well as the
training of specialized personnel, increased their success rates, making it the
most predictable procedure available. Although the number of randomized and
controlled studies is still limited, results from large multicentered registries
allow us to safely offer this intervention to patients, as another treatment
option along with the optimized drug treatment and myocardial revascularization
surgery. This review summarizes the last and most relevant publications in the
subject in order to provide an overall view of the field’s current status.
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Affiliation(s)
| | - Marcelo J C Cantarelli
- Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista, São Paulo, SP - Brazil.,Hospitais Leforte, São Paulo, SP - Brazil
| | - Viviana M G Lemke
- Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista, São Paulo, SP - Brazil.,Hospital das Nações, Curitiba, PR - Brazil.,Hospital do Rocio, Campo Largo, PR - Brazil
| | - Alexandre Schaan de Quadros
- Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista, São Paulo, SP - Brazil.,Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil
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25
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Kimura S, Sugiyama T, Hishikari K, Nakagama S, Nakamura S, Misawa T, Mizusawa M, Hayasaka K, Yamakami Y, Sagawa Y, Kojima K, Ohtani H, Hikita H, Takahashi A. Intravascular Ultrasound and Angioscopy Assessment of Coronary Plaque Components in Chronic Totally Occluded Lesions. Circ J 2018; 82:2032-2040. [PMID: 29910223 DOI: 10.1253/circj.cj-18-0186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The in vivo lesion morphologies and plaque components of coronary chronic total occlusion (CTO) lesions remain unclear.Methods and Results:We investigated 57 consecutive CTO lesions in 57 patients with stable angina pectoris undergoing elective percutaneous coronary intervention with intravascular ultrasound (IVUS) and coronary angioscopy (CAS) examination. All CTO lesions were classified according to the proximal angiographic lumen pattern; tapered-type (T-CTO) and abrupt-type (A-CTO). The differences in the intracoronary images of these lesion types were evaluated according to the location within the CTO segment. A total of 35 lesions (61.4%) were T-CTO. T-CTO lesions had higher frequencies of red thrombi (proximal 71.4%; middle 74.3%; distal 31.4%; P<0.001) and bright-yellow plaques (yellow-grade 2-3) (48.6%; 74.3%; 2.9%; P<0.001) at the proximal or middle than at the distal subsegment; A-CTO lesions showed no significant differences among the 3 sub-segments. At the middle subsegment, T-CTO lesions showed higher frequencies of positive remodeling (51.4% vs. 18.2%, P=0.01) and bright-yellow plaques (74.3% vs. 13.6%, P<0.001) compared with A-CTO lesions. Multivariate analysis identified bright-yellow plaque as an independent predictor (odds ratio, 7.25; 95% confidence interval, 1.25-42.04; P=0.03) of the occurrence of periprocedural myocardial necrosis. CONCLUSIONS The combination of IVUS and CAS analysis may be useful for identifying lesion morphology and plaque components, which may help clarify the pathogenetic mechanism of CTO lesions.
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Affiliation(s)
| | | | | | | | | | - Toru Misawa
- Cardiovascular Center, Yokosuka Kyosai Hospital
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26
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Harding SA, Wu EB, Lo S, Lim ST, Ge L, Chen JY, Quan J, Lee SW, Kao HL, Tsuchikane E. A New Algorithm for Crossing Chronic Total Occlusions From the Asia Pacific Chronic Total Occlusion Club. JACC Cardiovasc Interv 2018; 10:2135-2143. [PMID: 29122129 DOI: 10.1016/j.jcin.2017.06.071] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/12/2017] [Accepted: 06/29/2017] [Indexed: 12/21/2022]
Abstract
Although the hybrid chronic total occlusion (CTO) algorithm had many excellent recommendations, there has been infrequent adoption in the Asia Pacific region. The Asia Pacific CTO club propose an algorithm for case selection based on the Japan-CTO score and a new CTO algorithm, which is applicable globally. This algorithm allows for differing skill sets and equipment availability and contains practical teaching for CTO percutaneous coronary intervention. Similar to the hybrid algorithm there are 3 main questions that determine whether the primary approach is antegrade or retrograde: 1) is there proximal cap ambiguity; 2) is the distal vessel of poor quality; and 3) are there interventional collaterals present. In contrast to the hybrid algorithm occlusion length alone does not determine the choice of either a wire escalation strategy or a dissection re-entry strategy. Rather a combination of factors including ambiguity of the vessel course, severe calcification, tortuosity, length, and previous failure are used to determine this. The role of intravascular ultrasound-guided entry to overcome proximal cap ambiguity and the CrossBoss catheter in occlusive in-stent restenosis are highlighted in the algorithm. Both the parallel wire technique and dissection re-entry with the Stingray system have been included as options when the initial antegrade wire passage fails. Intravascular ultrasound-guided wiring along with limited subintimal tracking and re-entry are included as final options in the algorithm. Finally, the algorithm incorporates guidance on when to stop the procedure. It is hoped that this algorithm will serve as the basis for future CTO percutaneous coronary intervention proctoring and training.
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Affiliation(s)
- Scott A Harding
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand.
| | | | - Sidney Lo
- Liverpool Hospital, Sydney, Australia
| | | | - Lei Ge
- Shanghai Zhongshan Hospital, Shanghai, China
| | - Ji-Yan Chen
- Guangdong General Hospital, Guangdong, China
| | - Jie Quan
- Beijing Fuwai Hospital, Beijing, China
| | - Seung-Whan Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Hsien-Li Kao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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27
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Dash D. Coronary chronic total occlusion intervention: A pathophysiological perspective. Indian Heart J 2018; 70:548-555. [PMID: 30170652 PMCID: PMC6116719 DOI: 10.1016/j.ihj.2018.01.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 12/03/2022] Open
Abstract
Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is the last frontier in coronary intervention. PCI of CTO carries multiple advantages, such as significant improvement in symptoms, improvement in abnormal wall motion and left ventricular function and, possibly, increased long-term survival. As of today the procedural success is markedly improved because of technical innovations and is limited to highly experienced operators. To enhance the overall success rate from a worldwide perspective, a thorough understanding of its pathophysiology is critical to further development of newer techniques and technologies. In this review, the author outlines in-depth the evidence that underpins our understanding of CTO pathophysiology and its insight into CTO intervention that incorporates various steps and techniques to cross the lesion.
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Affiliation(s)
- Debabrata Dash
- Thumbay Hospital, Ajman, United Arab Emirates; Beijing Tiantan Hospital, Beijing, China.
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28
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Wu Q, Yu M, Li Y, Li W, Lu Z, Wei M, Yan J, Zhang J. Natural History of Untreated Coronary Total Occlusions Revealed with Follow-Up Semi-Automated Quantitative Coronary CT Angiography: The Morphological Characteristics of Initial CT Predict Occlusion Shortening. Korean J Radiol 2018. [PMID: 29520183 PMCID: PMC5840054 DOI: 10.3348/kjr.2018.19.2.256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective To investigate the morphological changes of coronary chronic total occlusion (CTO) as determined by coronary computed tomography angiography (CCTA) follow-up using semi-automated quantitative analysis. Materials and Methods Thirty patients with 31 CTO lesions confirmed by invasive coronary angiography and baseline/follow-up CCTA were retrospectively included. CTOs were quantitatively analyzed by a semi-automated coronary plaque analysis software (Coronary Plaque Analysis, version 2.0, Siemens) after manually determining the lesion border. Recanalized lumen was defined as the linear-like enhanced opacity traversing the non-opacified occluded segment. Other parameters, such as total occlusion length, total occlusion volume, volume with low attenuation component (< 30 Hounsfield unit [HU]), volume with middle to high attenuation component (30–190 HU) as well as the calcification volume, were also recorded. Results Recanalized lumen was found within 48.4% (15/31) occlusions on the follow-up CCTA, compared to 45.2% (14/31) occlusions on the baseline CCTA. Eleven of 14 lesions (78.6%) with CT-visible recanalized lumen within CTOs had a shorter occlusion length on follow-up compared to only 3 of 17 lesions (17.6%) without CT-visible recanalized lumen (odds ratio, 17.1, p < 0.001). The percentage of low attenuation component of occlusions was smaller on follow-up CCTA compared to baseline value (18.1 ± 20.1% vs. 22.6 ± 19.6%, p = 0.033). Conclusion Coronary computed tomography angiography enables non-invasive characterization of natural progression of untreated CTO lesions. Recanalized lumen within CTOs observed at baseline CCTA was associated with shortening of occlusion length on follow-up. Compared to their earlier stage, occlusions of later stage were presented with higher density of non-calcified components.
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Affiliation(s)
- Qian Wu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Mengmeng Yu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Yuehua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Wenbin Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Zhigang Lu
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Meng Wei
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Jing Yan
- Siemens Healthcare Ltd., Shanghai 201318, China
| | - Jiayin Zhang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
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29
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Yamamoto MH, Maehara A, Poon M, Guo J, Yamashita K, Yakushiji T, Saito S, Koyama K, Mintz GS, Ochiai M. Morphological assessment of chronic total occlusions by combined coronary computed tomographic angiography and intravascular ultrasound imaging. Eur Heart J Cardiovasc Imaging 2018; 18:315-322. [PMID: 27099278 DOI: 10.1093/ehjci/jew077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 03/21/2016] [Indexed: 01/17/2023] Open
Abstract
Aims The relationship between CTO morphology and vessel remodelling is unclear. We described chronic total occlusion (CTO) morphology using coronary computed tomographic angiography (CCTA) combined with intravascular ultrasound (IVUS). Methods and results Pre-intervention CCTA and IVUS of 130 CTO lesions (128 patients) were evaluated. Based on CCTA, positive CTO lesion remodelling [PR, maximum CTO segment vessel diameter > proximal reference vessel diameter (RVD)] was seen in 44 (33.8%) lesions. In the other 86 lesions without PR, 74 (56.9%) had a minimum CTO segment vessel diameter >50% of the proximal RVD and were classified as non-PR; 12 (9.2%) lesions had a minimum CTO segment vessel diameter ≤50% of the proximal RVD and were classified as collapse. Comparing the three groups, CTO with PR had the greatest maximum atheroma cross-sectional area (CSA) while the collapse group had the least atheroma CSA (16.0 mm2 [12.0, 19.4] vs. 9.1 mm2 [6.0, 15.9], P < 0.001). The maximum arc of attenuated plaque was greatest in the PR group (51° [0, 167]); and the maximum arc of calcium was greatest in the non-PR group (91° [51, 174]). In the collapse group distal to the occluded segment, there was a normal-appearing vessel by IVUS that corresponded to the collapsed segment by CCTA; its minimum plaque burden was 33.2% [19.9, 38.1] with a smooth concave-shaped lumen surface, implying that the CCTA collapse segment was not occluded. Conclusion Not all CTOs are the same with regard to lesion remodelling and underlying morphology. The combination of IVUS and CCTA can help to categorize CTO morphology.
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Affiliation(s)
- Myong Hwa Yamamoto
- Cardiovascular Research Foundation, 111 East 59th Street, New York, NY, USA.,Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Akiko Maehara
- Cardiovascular Research Foundation, 111 East 59th Street, New York, NY, USA.,Columbia University Medical Center, New York, NY, USA
| | - Michael Poon
- Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Jun Guo
- Chinese PLA General Hospital, Beijing, China
| | | | | | - Shigeo Saito
- Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Kohei Koyama
- Cardiovascular Research Foundation, 111 East 59th Street, New York, NY, USA
| | - Gary S Mintz
- Cardiovascular Research Foundation, 111 East 59th Street, New York, NY, USA
| | - Masahiko Ochiai
- Showa University Northern Yokohama Hospital, Yokohama, Japan
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30
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Leibundgut G, Kaspar M. Chronic Total Occlusions. Interv Cardiol 2017. [DOI: 10.5772/68067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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31
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Tan Y, Zhou J, Zhang W, Zhou Y, Du L, Tian F, Guo J, Chen L, Cao F, Chen Y. Comparison of CT-RECTOR and J-CTO scores to predict chronic total occlusion difficulty for percutaneous coronary intervention. Int J Cardiol 2017; 235:169-175. [PMID: 28274578 DOI: 10.1016/j.ijcard.2017.02.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 01/02/2017] [Accepted: 02/01/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND We sought to evaluate the ability of the CT-RECTOR and J-CTO scores to predict time-efficient guidewire (GW) crossing through a chronic total occlusion (CTO) and final procedure success. METHODS Data from 191 consecutive CTO lesions with pre-procedural coronary computed tomography angiography (CCTA) from our center were analyzed retrospectively. The difficulty of the procedure was classified as easy, intermediate, difficult, or very difficult according to CT-RECTOR and J-CTO scores. A successful GW crossing within 30min was set as the first endpoint. Final success of the procedure was set as the second endpoint. Receiver operating characteristic curves and net reclassification improvement (NRI) were used to compare the performance of both scores in predicting both endpoints. RESULTS The first and second endpoints were achieved in 55% and 76% of lesions, respectively. The NRI for prediction for both endpoints were 30.21% and 28.94%, respectively. Use of the CT-RECTOR score demonstrated a positive NRI for both the first (p=0.0027) and second (p=0.0190) endpoints. Compared with the J-CTO score (area under the curve: 0.76), the CT-RECTOR score (area under the curve: 0.85) yielded a higher predictive value for successful GW crossing within 30min (p=0.0018). CONCLUSIONS Compared with J-CTO, the CT-RECTOR scoring system provides a more accurate noninvasive tool for predicting time-efficient GW crossing and final procedure success. This scoring system, which is based on CCTA, may aid in the identification of very difficult CTO lesions and downstream management.
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Affiliation(s)
- Yahang Tan
- Department of Cardiology, Chinese PLA General Hospital, China; School of Medicine, Nankai University, China
| | - Jia Zhou
- Department of Cardiology, Chinese PLA General Hospital, China; Department of Cardiology, Tianjin Chest Hospital, China
| | - Wei Zhang
- Department of Cardiology, Chinese PLA General Hospital, China
| | - Ying Zhou
- Department of Cardiology, Chinese PLA General Hospital, China; Department of Cardiology, SHIJITAN Hospital, China
| | - Luoshan Du
- Department of Radiology, Chinese PLA General Hospital, China
| | - Feng Tian
- Department of Cardiology, Chinese PLA General Hospital, China
| | - Jun Guo
- Department of Cardiology, Chinese PLA General Hospital, China
| | - Lian Chen
- Department of Cardiology, Chinese PLA General Hospital, China
| | - Feng Cao
- Department of Cardiology, Chinese PLA General Hospital, China
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, China.
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32
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Association between duration of coronary occlusion and high-intensity signal on T1-weighted magnetic resonance imaging among patients with angiographic total occlusion. Eur Radiol 2017; 27:3896-3903. [PMID: 28155111 PMCID: PMC5544795 DOI: 10.1007/s00330-016-4672-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/15/2016] [Accepted: 11/23/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To evaluate the association between duration of the coronary occlusion and high-intensity signal (HIS) on noncontrast T1-weighted imaging using a 1.5-T magnetic resonance imager among patients with angiographic coronary total occlusion. METHODS The signal intensity of the coronary target area divided by the signal intensity of the left ventricular muscle near the target area at each site (TMR) was measured. Areas with a TMR >1.0 were defined as HIS. Thirty five lesions from 33 patients were divided into the following three groups: subacute occlusion (up to 3 months; n = 7), short-duration chronic total occlusion (SD-CTO: 3-6 months; n = 9) and long-duration CTO (LD-CTO: ≥6 months; n = 19). RESULTS All subacute occlusion lesions showed a HIS within the occlusion site. Among patients with CTO, the frequency of a HIS within the occlusion site was significantly higher in SD-CTO than in LD-CTO lesions (p = 0.013). In multivariate analyses, only an occlusion duration of less than 6 months was an independent factor associated with the presence of HIS (odds ratio 7.6, 95% CI 1.1-54.5; p = 0.044). CONCLUSIONS The presence of a HIS in the occlusion site was associated more with SD-CTO than with LD-CTO among patients with CTO. KEY POINTS • All subacute occlusion lesions show a high-intensity signal on T1-weighted imaging. • HIS within occlusion sites is associated with subacute or short-duration total occlusion. • T1-weighted imaging for coronary total occlusion may be useful for intervention strategy.
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33
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Ikari Y, Awata M, Mitsudo K, Akasaka T, Saito S, Ishihara T, Fujii T, Hashimoto H, Terashima M, Ikemoto T, Hibi K, Tazaki J, Nakamura A, Nishikawa H, Sato T, Nakagawa Y. Efficient distal tip size of primary guidewire for antegrade percutaneous coronary intervention in chronic total occlusion: The G-FORCE study. Int J Cardiol 2017; 227:94-99. [PMID: 27855293 DOI: 10.1016/j.ijcard.2016.11.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 11/05/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although several new techniques have been introduced for CTO such as the retrograde approach, the fundamental question of what type of guidewire is the most appropriate as a primary guidewire in the antegrade approach has not been answered. METHODS The G-FORCE study was designed as a prospective multicenter randomized controlled trial to determine the efficient primary guidewire in antegrade approach for chronic total occlusion (CTO). The first guidewire was randomly assigned to a regular size distal tip group (0.014in. size) or tapered tip group (0.010in. or less). The primary endpoint was defined as successful lesion penetration by the first guidewire into distal true lumen. This study was registered at ClinicalTrials.gov with identifier NCT00987610. RESULTS A total of 260 patients were enrolled, with an average age of 66±11years and 16% were female. The average J-CTO score was 1.8±1.1. The primary endpoint was achieved in 38% and 32% of patients using tapered and regular distal tip guidewires, respectively (P=0.80). The final PCI success rate was 81% vs. 85%, respectively (P=0.57). Easy CTO lesions with a J-CTO score=0 exhibited a primary endpoint significantly different between tapered and regular distal tip primary guidewires (79% vs. 40%; P=0.046). Guidewire distal coating or distal tip load did not relate with primary guidewire success rate. CONCLUSION Tapered and regular distal tip guidewires are equivalent as a first choice for CTO. Tapered guidewires are superior for CTO lesions with a J-CTO score=0.
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Affiliation(s)
- Yuji Ikari
- Tokai University School of Medicine, Isehara, Japan.
| | | | | | | | | | | | | | | | | | | | - Kiyoshi Hibi
- Yokohama City University Medical Center, Yokohama, Japan
| | - Junichi Tazaki
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Kang J, Jeon KH, Kim SW, Park JJ, Yoon CH, Suh JW, Cho YS, Youn TJ, Chae IH, Choi DJ. Evolution of nonculprit coronary atherosclerotic plaques assessed by serial virtual histology intravascular ultrasound in patients with ST-segment elevation myocardial infarction and chronic total occlusion. Coron Artery Dis 2016; 27:650-657. [PMID: 27501406 PMCID: PMC5087572 DOI: 10.1097/mca.0000000000000419] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/28/2016] [Accepted: 07/12/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The pathophysiology and natural course of coronary nonculprit plaques remain unclear. We investigated whether the short-term natural course of nonculprit plaques differs between ST-segment elevation myocardial infarction (STEMI) and chronic total occlusion (CTO) patients. METHODS We performed serial virtual histology intravascular ultrasound on nonculprit plaques in 26 STEMI and 11 CTO lesions at baseline and the 6-month follow-up. RESULTS At baseline, more lesions in the STEMI group were virtual histology intravascular ultrasound-derived thin-cap fibroatheromas (TCFA; 76.9 vs. 18.1%, P=0.002). During the follow-up period, the plaque composition changed dynamically in the STEMI group (fibrofatty: 9.8±1.9 to 17.3±2.9%, P=0.030; dense calcium: 12.7±1.8 to 8.1±1.7%, P=0.026; necrotic core: 21.1±1.8 to 15.4±2.2%, P=0.052), with a consistent plaque size. In the CTO group, the plaque composition and plaque size remained consistent without a significant change. Also, more lesions in the STEMI group remained as or progressed to TCFA, compared with the CTO group (67 vs. 11%, P=0.089). Factors associated with a persistent TCFA or with a new development of TCFA were a large necrotic core volume index and the diagnosis of STEMI, whereas new statin usage was a protective factor. CONCLUSION Nonculprit lesions in STEMI patients were more unstable at the baseline compared with those in CTO patients. During follow-up, nonculprit lesions in STEMI and CTO patients showed a distinct pattern of change; the former were stabilized in plaque composition, whereas the latter remained consistent. The diagnosis of STEMI and a large necrotic core volume were predictors of evolution to a TCFA, and new statin usage was a protective factor.
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Affiliation(s)
- Jeehoon Kang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ki-Hyun Jeon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Seong-Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Jin Joo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Chang-Hwan Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Jung-Won Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Young-Seok Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Tae-Jin Youn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - In-Ho Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Dong-Ju Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam
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Werner GS, Brilakis ES. Chronic Total Coronary Occlusion. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Emmanouil S. Brilakis
- Cardiac Catheterization Laboratories; VA North Texas Health Care System; Dallas TX USA
- Minneapolis Heart Institute; Minneapolis MN USA
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Sakakura K, Yahagi K, Virmani R, Joner M. Pathology of Coronary Chronic Total Occlusion. Int Cardiovasc Res J 2016. [DOI: 10.17795/icrj-10(2)55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Plasma homocysteine levels are related to medium-term venous graft degeneration in coronary artery bypass graft patients. Anatol J Cardiol 2016; 16:868-873. [PMID: 27147400 PMCID: PMC5324890 DOI: 10.14744/anatoljcardiol.2016.6738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: Saphenous venous grafts (SVGs) are established choices for coronary artery bypass grafting (CABG); however, their lumen patency is limited. Our goal was to investigate the risk factors of SVG degeneration. Methods: Seventy-five patients (mean age, 57.5±10.4 years) with 133 SVG conduits who had cardiac catheterization ≥1 year after CABG were selected; follow-up period was 67.6±36.8 months. Patients were divided into 3 groups according to angiographic status at follow up [intact: <20% (n=23); narrowed: 20–99% (n=24); and occluded (n=28)]. Baseline clinical conditions were evaluated in relation to follow-up angiography. As onset date of chronic total occlusions is usually uncertain, they arise typically from thrombotic lesions; thus, their value in evaluation is limited. Results: There were no significant differences between the 3 groups in clinical parameters. Linear correlation analysis found significant (p<0.01) positive connection of SVG disease (luminal diameter reduction 20–99%) with C-reactive protein (CRP) and homocysteine (Hcy), as well as between CRP and Hcy. Multiple regression analysis showed plasma Hcy level to be significantly related to graft diameter reduction normalized to time elapsed until angiography in narrowed grafts: 1 µmol/L increase of Hcy was associated with 0.053%/month decrease in lumen diameter (p<0.01; R2=0.428); extrapolating: +10 µmol/L higher Hcy level during 5 years is associated with 32.1% lumen reduction. Conclusion: Medium- to long-term SVG degeneration is related to elevated plasma total Hcy in patients with sub-occlusive graft stenosis, while in cases with intact SVGs, the beneficial local flow conditions may protect the grafts from degeneration.
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Dash D. Guidewire crossing techniques in coronary chronic total occlusion intervention: A to Z. Indian Heart J 2016; 68:410-20. [PMID: 27316507 PMCID: PMC4912030 DOI: 10.1016/j.ihj.2016.02.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 01/29/2016] [Accepted: 02/24/2016] [Indexed: 11/18/2022] Open
Abstract
Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) poses a management dilemma for the interventional cardiologist. Effective wiring technique is the key to success of PCI in CTO, which requires more patience and skill of the operator. The author herein intends to explore in detail the different wiring strategies such as antegrade approach, dissection and reentry, retrograde and hybrid approach. Hopefully, this review would enhance the understanding of this complex procedure and, consequently, promote safe and effective PCI.
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Affiliation(s)
- Debabrata Dash
- Interventional Cardiologist, S. L Raheja (A Fortis Associate) Hospital, Nanavati Superspeciality Hospital, Mumbai, India(1); Guest Professor of Cardiology, Beijing Tiantan Hospital, Beijing, China.
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39
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Choi C, Agarwal N, Park K, Anderson RD. Coronary Artery Chronic Total Occlusion. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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40
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Kim SM, Choi JH, Choe YH. Coronary Artery Total Occlusion: MR Angiographic Imaging Findings and Success Rates of Percutaneous Coronary Intervention according to Intraluminal Signal Intensity Patterns. Radiology 2016; 279:84-92. [DOI: 10.1148/radiol.2015150191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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41
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Sianos G, Konstantinidis NV, Di Mario C, Karvounis H. Theory and practical based approach to chronic total occlusions. BMC Cardiovasc Disord 2016; 16:33. [PMID: 26860695 PMCID: PMC4746803 DOI: 10.1186/s12872-016-0209-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 12/21/2022] Open
Abstract
Coronary chronic total occlusions (CTOs) represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. The complexity of these procedures and the suboptimal success rates over a long period of time, along with the perception that CTOs are lesions with limited scope for recanalization, account for the underutilization of CTO Percutaneous Coronary Intervention (PCI). During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardization of modern CTO recanalization techniques, achieving success rates far beyond 90%, while coping with lesions of increasing complexity. Numerous studies support the rationale of CTO revascularization following documentation of viability and ischemia in the territory distal to the CTO. Successful CTO PCI provide better tolerance in case of future acute coronary syndromes and can significantly improve angina and left ventricular function. Randomized trials are on the way to further explore the prognostic benefit of CTO revascularization. The following review reports on the theory and the most recent advances in the field of CTO recanalization, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries.
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Affiliation(s)
- Georgios Sianos
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Nikolaos V Konstantinidis
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Carlo Di Mario
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
| | - Haralambos Karvounis
- 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
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Tran P, Phan H, Shah SR, Latif F, Nguyen T. Applied Pathology for Interventions of Coronary Chronic Total Occlusion. Curr Cardiol Rev 2015; 11:273-276. [PMID: 26354510 PMCID: PMC4774629 DOI: 10.2174/1573403x11666150909110915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/04/2015] [Indexed: 11/30/2022] Open
Abstract
Percutaneous coronary intervention of chronically occluded vessels can result in significant improvement in
symptoms, relieve myocardial ischemia, and affect a reduction in major adverse cardiac events. Likelihood of achieving
successful revascularization can be significantly enhanced with a thorough understanding of the pathology of these occluded
coronary arteries. In this chapter, various steps and techniques to cross the CTO lesion and recanalize it are discussed
in details.
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43
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Yu M, Xu N, Zhang J, Li Y, Li M, Lu Z, Wei M, Lu B. CT features in the early and late stages of chronic total coronary occlusions. J Cardiovasc Comput Tomogr 2015; 9:572-7. [DOI: 10.1016/j.jcct.2015.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 07/09/2015] [Accepted: 07/26/2015] [Indexed: 10/23/2022]
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Irving J. CTO pathophysiology: how does this affect management? Curr Cardiol Rev 2015; 10:99-107. [PMID: 24694103 PMCID: PMC4021289 DOI: 10.2174/1573403x10666140331142349] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Revised: 12/15/2013] [Accepted: 01/20/2014] [Indexed: 11/22/2022] Open
Abstract
Chronic total occlusion (CTO)
pathophysiology has been described in a few, small studies using post mortem
histology, and more recently, in vivo intravascular ultrasound (IVUS) to
analyse the constituents of occluded segments. Recent improvements in equipment
and techniques have revealed new insights into physical characteristics of
occluded coronaries, which in turn enable predictable procedural success. The
purpose of this review is to consider the published evidence describing CTO
pathophysiology from the perspective of the hybrid algorithm approach to CTO
PCI. Methods: Literature
searches using “Chronic Occlusion”, “angioplasty”, and” pathology” as keywords.
Further searches on “coronary” “collateral”, “Viability”. Bibliographies were
scrutinised for further key publications in an iterative process. Papers
describing animal models were excluded.
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45
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Kim NY, Lim KS, Jeong MH, Bae IH, Park JK, Nah JW, Park DS, Lee SY, Jang EJ, Kim JM, Kim JH, Kee HJ, Cho SN, Sim DS, Park KH, Hong YJ, Oh SG, Kim SH, Ahn Y, Kang JC. Reliable femoral chronic total occlusion model using a thin biodegradable polymer coated copper stent in a porcine model. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2015; 26:172. [PMID: 25804307 DOI: 10.1007/s10856-015-5506-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 02/09/2015] [Indexed: 06/04/2023]
Abstract
Chronic total occlusions (CTOs) are common in patients with peripheral arterial disease (PAD). This study aimed to examine the feasibility and reliability of a CTO induced by a thin biodegradable polymer (polyglycolic acid) coated copper stent in a porcine femoral artery. Novel thin biodegradable polymer coated copper stents (9 mm long) were crimped on an angioplasty balloon (4.5 mm diameter × 12 mm length) and inserted into the femoral artery. Histopathologic analysis was performed 35 days after stenting. In five of six stented femoral arteries, severe in-stent restenosis and total occlusion with collateral circulation were observed without adverse effects such as acute stent thrombosis, leg necrosis, or death at 5 weeks. Fibrous tissue deposition, small vascular channels, calcification, and inflammatory cells were observed in hematoxylin-eosin, Carstair's, and von Kossa tissue stains; these characteristics were similar to pathological findings associated with CTOs in humans. The neointima volume measured by micro-computed tomography was 93.9 ± 4.04 % in the stented femoral arteries. CTOs were reliably induced by novel thin biodegradable polymer coated copper stents in porcine femoral arteries. Successful induction of CTOs may provide a practical understanding of their formation and application of an interventional device for CTO treatment.
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Affiliation(s)
- Nan Yeol Kim
- Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
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Pernès JM, Auguste M, Borie H, Kovarsky S, Bouchareb A, Despujole C, Coppé G. Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics. Diagn Interv Imaging 2015; 96:423-34. [PMID: 25704905 DOI: 10.1016/j.diii.2014.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 06/04/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022]
Abstract
The world is facing an epidemic of diabetes; consequently in the next years, critical limb ischemia (CLI) due to diabetic arterial disease, characterized by multiple and long occlusions of below-the-knee (BTK) vessels, will become a major issue for vascular operators. Revascularization is a key therapy in these patients as restoring adequate blood supply to the wound is essential for healing, thus avoiding major amputations. Endoluminal therapy for BTK arteries is now a key part of the vascular specialist armamentarium. Tibial artery endovascular approaches have been shown to achieve high limb salvage rates with low morbidity and mortality and endovascular interventions one should now consider to be the first line treatment in the majority of CLI patients, especially in those with associated medical comorbidities. To do so, the vascular specialist requires detailed knowledge of the BTK endovascular techniques and devices. The first step decision in tibial endovascular therapy is access. In this context, the anterograde ipsilateral approach is generally preferred. The next critical decision is the choice of the vessel(s) to be approached in order to achieve successful limb salvage. Obtaining pulsatile flow to the correct portion of the foot is the paramount for ulcer healing. As such, a good understanding of the current angiosome model should enhance clinical results. The devices used should be carefully selected and optimal choice of guide wire is also extremely important and should be based on the characteristics of the lesion (location, length, and stenosis/occlusion) together with the characteristics of the guide wire itself (tip load, stiffness, hydrophilic/hydrophobic coating, flexibility, torque transmission, trackability, and pushability). Passing through chronic total occlusions can be quite challenging. The vascular interventional radiologist needs therefore to master the techniques that have been recently described: anterograde approaches, including the drilling technique, the penetrating technique, the subintimal technique and the parallel technique; subintimal arterial flossing with anterograde-retrograde procedures (Safari); the pedal-plantar loop technique and revascularization through collateral fibular artery vessels.
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Affiliation(s)
- J-M Pernès
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France.
| | - M Auguste
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - H Borie
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - S Kovarsky
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - A Bouchareb
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - C Despujole
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - G Coppé
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
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Touma G, Ramsay D, Weaver J. Chronic total occlusions - Current techniques and future directions. IJC HEART & VASCULATURE 2015; 7:28-39. [PMID: 28785642 PMCID: PMC5497190 DOI: 10.1016/j.ijcha.2015.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 09/28/2014] [Accepted: 02/01/2015] [Indexed: 11/24/2022]
Abstract
Chronic total occlusions (CTOs) of coronary arteries represent a common and significant challenge to interventional cardiology. Medical therapy is often regarded as an adequate long term strategy in the management of these lesions with surgical intervention for refractory symptoms. Extensive collateralisation is used as a marker of distal coronary perfusion, further reinforcing non-invasive strategies. This together with relatively low percutaneous success rates outside of specialised centres has meant that rates of percutaneous intervention have remained low. Increasing evidence suggests that CTOs are not a benign entity. Further, symptom control and quality of life improve significantly with successful percutaneous revascularisation. Both factors have reignited interest in percutaneous modalities. The Japanese have been pioneers in the field of CTO intervention although their success rates have been difficult to replicate. New techniques and equipment developed in North America offer an alternative to the Japanese approach. These techniques focus on time, radiation and contrast minimisation. This review will assess the histopathology of CTO and shifting paradigms in CTO treatment strategies. Chronic total occlusions are common and prognostically important. Strategies for chronic occlusions are pioneered by Japanese, adapted by North American operators. Japanese and North American strategies appear divergent, both add considerable expertise.
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Affiliation(s)
- George Touma
- Department of Cardiology, The St George Hospital, Kogarah, Sydney, Australia
| | - David Ramsay
- Department of Cardiology, The St George Hospital, Kogarah, Sydney, Australia
| | - James Weaver
- Department of Cardiology, The St George Hospital, Kogarah, Sydney, Australia
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49
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Galassi A, Grantham A, Kandzari D, Lombardi W, Moussa I, Thompson C, Werner G, Chambers C, Brilakis E. Percutaneous Treatment of Coronary Chronic Total Occlusions Part 1: Rationale and Outcomes. Interv Cardiol 2014; 9:195-200. [PMID: 29588802 DOI: 10.15420/icr.2014.9.3.195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Coronary chronic total occlusions (CTOs) are commonly encountered in patients with coronary artery disease. Compared to patients without coronary CTOs, those with CTO have worse clinical outcomes and lower likelihood of complete coronary revascularisation. Successful CTO percutaneous coronary intervention (PCI) can significantly improve angina and improve left ventricular function. Although currently unproven, successful CTO PCI might also reduce the risk for arrhythmic events in patients with ischaemic cardiomyopathy, provide better tolerance of future acute coronary syndrome, and possibly improve survival. Evaluation by a heart team comprised of both interventional and non-interventional cardiologists and cardiac surgeons is important for determining the optimal revascularisation strategy in patients with coronary artery disease and CTOs. Ad hoc CTO PCI is generally not recommended, so as to allow sufficient time for (a) discussion with the patient about the indications, goals, risks, and alternatives to PCI; (b) careful procedural planning; and (c) contrast and radiation exposure minimisation. Use of drug-eluting stents is recommended for CTO PCI, given the lower rates of angiographic restenosis compared to bare metal stents.
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Affiliation(s)
| | - Aaron Grantham
- Saint Luke's Mid America Heart Institute and University of Missouri Kansas City, Missouri, US
| | | | | | | | | | | | - Charles Chambers
- Penn State University College of Medicine, Hershey, Pennsylvania, US
| | - Emmanouil Brilakis
- VA North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, US
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50
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Konstantinidis N, Pighi M, Dogu Kilic I, Serdoz R, Sianos G, Di Mario C. New Advances in Chronic Total Occlusions. Interv Cardiol 2014; 9:208-212. [PMID: 29588804 DOI: 10.15420/icr.2014.9.3.208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Coronary chronic total occlusions (CTOs) still represent the greatest technical challenge that interventional cardiologists face. CTOs remain seriously undertreated with percutaneous techniques, far below their prevalence. One reason for the low uptake was the suboptimal CTO percutaneous coronary intervention (PCI) success rates over a long period of time. During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardisation of modern CTO recanalisation techniques, along with providing focused training and proctorship worldwide. As a result, dedicated operators achieved success rates far beyond 90 %, while coping with lesions of increasing complexity. A series of studies, mainly retrospective and observational in nature, explored the prognostic impact of CTO PCI, revealing that successful lesion recanalisation is related to improved patient outcome and anginal status; further evidence from randomised trials is on the way. The following review reports on the most recent advances in the field of CTO recanalisation, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries and encourage more operators to cope with these inherently complex lesions.
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Affiliation(s)
- Nikolaos Konstantinidis
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.,1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Michele Pighi
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Ismail Dogu Kilic
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Roberta Serdoz
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Georgios Sianos
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Carlo Di Mario
- National Institute for Health Research (NIHR) Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
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