Use of the Carlino Technique in Chronic Total Occlusion Percutaneous Coronary Intervention

Dissection Techniques in Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND

There is limited data on dissection strategies in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

AIMS

To study the differences in the baseline characteristics and procedural outcomes of antegrade CTO PCIs that used dissection strategies.

METHODS

We performed a comparative analysis of antegrade dissection and re-entry CTO PCIs from the PROGRESS-CTO registry from 50 centers (2012-2024). Three dissection strategies were compared: (a) knuckle wiring: knuckle wire(s) without Carlino technique or CrossBoss catheter; (b) the CrossBoss technique: use of the CrossBoss catheter; and (c) the Carlino technique: use of the Carlino technique. In-stent CTO PCIs were excluded from the analysis.

RESULTS

In total, 1575 (74.6%) cases used knuckle wiring, 427 (20.2%) the CrossBoss, and 110 (5.2%) the Carlino technique. Knuckle wiring was the most frequent strategy with increasing utilization over time (p < 0.001). The CrossBoss catheter was more common in lesions with lower J-CTO scores (CrossBoss: 2.91 vs. Knuckle wiring: 3.07 vs. Carlino: 3.18; p = 0.015), and was associated with higher technical success (CrossBoss: 84.0% vs. Knuckle wiring: 74.2% vs. Carlino: 64.2%; p < 0.001) and similar major adverse cardiac events rates, but lower perforation rates. Time to crossing was longer when Carlino was used (CrossBoss: 93 [70, 133] min vs. Knuckle wiring: 97 [63, 136] min vs. Carlino: 133 [84, 166] min, p = 0.001). Use of different types of knuckle wires (Pilot 200, Gladius Mongo, and Fielder XT) was associated with similar success rates.

CONCLUSIONS

Knuckle wiring is the most commonly used antegrade dissection strategy. The CrossBoss catheter was used in less complex cases and was associated with higher success, whereas the opposite was true for the Carlino technique.

Complete Revascularization of Multiple Coronary CTOs in a Single Session Using Hydrodynamic Contrast Recanalization

Background

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is technically more challenging than non‐CTO PCI. The development of novel CTO‐specific PCI techniques, such as hydrodynamic contrast recanalization (HDR), has led to improved technical success with low complication rates. We present a case of successful single‐session PCI of multiple CTOs using HDR in an elderly patient. Our report highlights the feasibility and advantages of single‐session complete revascularization in patients with multiple CTOs.

Case Presentation

A 71‐year‐old woman with multiple comorbidities, including CAD, heart failure with reduced ejection fraction (HFrEF), chronic kidney disease stage 3 (CKD), and lung cancer in remission, was admitted with NYHA class IV symptoms. Coronary angiography revealed CTO of all three major coronary arteries. Given her high surgical risk and frailty, percutaneous revascularization was recommended by the Heart Team. The patient underwent successful HDR‐facilitated CTO PCI of the left anterior descending (LAD), left circumflex (LCX), and right coronary arteries (RCA) in a single session. TIMI 3 flow was restored in all three vessels after successful drug‐eluting stent (DES) placement. The patient's symptoms markedly improved postprocedure.

Discussion

HDR is a novel CTO crossing technique that uses contrast modulation beyond the boundary of the proximal cap to facilitate the passage of polymer‐jacketed wires. Reported advantages of HDR include a faster crossing time and side branch preservation. Using HDR, we recanalized multiple CTOs in an elderly patient in under 3 h, achieving single‐session complete revascularization that improved clinical outcomes and minimized repeat procedural risks. This case highlights the potential role of HDR as a safe and efficient adjunct to conventional CTO PCI techniques in achieving optimal outcomes.

Complete Revascularization of Multiple Coronary CTOs in a Single Session Using Hydrodynamic Contrast Recanalization

BACKGROUND

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is technically more challenging than non-CTO PCI. The development of novel CTO-specific PCI techniques, such as hydrodynamic contrast recanalization (HDR), has led to improved technical success with low complication rates. We present a case of successful single-session PCI of multiple CTOs using HDR in an elderly patient. Our report highlights the feasibility and advantages of single-session complete revascularization in patients with multiple CTOs.

CASE PRESENTATION

A 71-year-old woman with multiple comorbidities, including CAD, heart failure with reduced ejection fraction (HFrEF), chronic kidney disease stage 3 (CKD), and lung cancer in remission, was admitted with NYHA class IV symptoms. Coronary angiography revealed CTO of all three major coronary arteries. Given her high surgical risk and frailty, percutaneous revascularization was recommended by the Heart Team. The patient underwent successful HDR-facilitated CTO PCI of the left anterior descending (LAD), left circumflex (LCX), and right coronary arteries (RCA) in a single session. TIMI 3 flow was restored in all three vessels after successful drug-eluting stent (DES) placement. The patient's symptoms markedly improved postprocedure.

DISCUSSION

HDR is a novel CTO crossing technique that uses contrast modulation beyond the boundary of the proximal cap to facilitate the passage of polymer-jacketed wires. Reported advantages of HDR include a faster crossing time and side branch preservation. Using HDR, we recanalized multiple CTOs in an elderly patient in under 3 h, achieving single-session complete revascularization that improved clinical outcomes and minimized repeat procedural risks. This case highlights the potential role of HDR as a safe and efficient adjunct to conventional CTO PCI techniques in achieving optimal outcomes.

HydroDynamic contrast Recanalization (HDR): Description of a new crossing technique for coronary chronic total occlusions

BACKGROUND

Intraplaque delivery of contrast has been utilized during percutaneous coronary interventions (PCI) of chronic total occlusions (CTO) to delineate anatomy and to facilitate wire crossing. Its utility as a tool to accomplish primary crossing of CTOs has not been described or validated.

AIMS

We describe a new technique leveraging the diagnostic and therapeutic roles of intraplaque contrast injection to accomplish primary crossing of CTOs: HydroDynamic contrast Recanalization (HDR).

METHODS

HDR is an antegrade crossing method for coronary CTOs based on the synergistic use of contrast microinjections and polymer jacketed wires. We present a retrospective, first-in-man, case series utilizing HDR for CTO PCI in patients with favorable CTO anatomy (visible proximal segment and identifiable distal target). The primary outcome was procedural success. The secondary outcome was any procedural complications.

RESULTS

A total of 43 patients with 45 CTOs underwent CTO PCI with HDR. Mean patient age was 64.3 ± 11 years. The mean Japanese CTO and PROGRESS CTO scores were 2.3 ± 0.7 and 1.8 ± 0.7, respectively. CTO complexity was high, with an ambiguous or blunt cap in 34 occlusions (76%); lesion length ≥ 20 mm in 27 occlusions (60%); and moderate/heavy calcification in 36 occlusions (80%). Procedural success using HDR was 100%. There were no complications.

CONCLUSIONS

This study shows the utility of HDR in CTO PCI. HDR appears to be a safe and promising new contrast-based primary crossing technique in selected patients. This strategy warrants further evaluation in larger prospective studies.

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

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