Chronic Total Occlusion Wiring: A State-of-the-Art Guide From The Asia Pacific Chronic Total Occlusion Club

Global Consensus Recommendations on Improving the Safety of Chronic Total Occlusion Interventions

Safety is of critical importance to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). This global consensus statement provides guidance on how to optimise the safety of CTO) PCI, addressing the following 12 areas: 1. Set-up for safe CTO PCI; 2. Guide catheter--associated vessel injuries; 3. Hydraulic dissection, extraplaque haematoma expansion, and aortic dissections; 4. Haemodynamic collapse during CTO PCI; 5. Side branch occlusion; 6. Perforations; 7. Equipment entrapment; 8. Vascular access considerations; 9. Contrast-induced acute kidney injury; 10. Radiation injury; 11 When to stop; and, 12. Proctorship. This statement complements the global CTO crossing algorithm; by advising how to prevent and deal with complications, this statement aims to facilitate clinical practice, research, and education relating to CTO PCI.

Comparative Analysis of Polymer Versus Non-Polymer Jacketed Wires in Chronic Total Occlusion Percutaneous Coronary Intervention

There is significant variation in wire utilization patterns for chronic total occlusion (CTO) percutaneous coronary intervention. This study aimed to compare the outcomes of polymer-jacketed wires (PJWs) versus non-PJWs in anterograde procedures. We analyzed clinical and angiographic characteristics, and procedural outcomes of 7,575 anterograde CTO percutaneous coronary interventions that were performed at 47 centers between 2012 and 2023. Cases in which PJWs were exclusively used were classified in the PJW group, whereas cases where at least one non-PJW was employed were classified in the non-PJW group. Study end points were as follows: technical success, coronary perforation, major adverse cardiac event. PJWs were exclusively used in 3,481 cases (46.0%). These cases had lower prevalence of proximal cap ambiguity, blunt stump, and moderate/severe calcification. They also had lower Japanese CTO (J-CTO), Prospective Global Registry for the Study of Chronic Total Occlusion (PROGRESS-CTO), and PROGRESS-CTO complications scores, higher technical success (94.3% vs 85.7%, p <0.001), and lower perforation rates (2.2% vs 3.2%, p = 0.013). Major adverse cardiac event rates did not differ between groups (1.3% vs 1.5%, p = 0.53). Exclusive use of PJWs was independently associated with higher technical success in both the multivariable (odds ratio [OR] 2.66, 95% confidence interval [CI] 2.13 to 3.36, p <0.001) and inverse probability of treatment weight analysis (OR 2.43, 95% CI 2.04 to 2.89, p <0.001). Exclusive use of PJWs was associated with lower risk of perforation in the multivariable analysis (OR 0.69, 95% CI 0.49 to 0.95, p = 0.02), and showed a similar trend in the inverse probability of treatment weight analysis (OR 0.77, 95% CI 0.57 to 1.04, p = 0.09). Exclusive use of PJWs is associated with higher technical success and lower perforation risk in this non-randomized series of patients.

New Angiographic Difficulty Score for First-Attempt Chronic Total Occlusion in the 3 Major Coronary Arteries

BACKGROUND

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is still challenging due to complex lesion morphology. Success rates may vary among the 3 major coronary arteries, influenced by clinical and angiographic characteristics.

OBJECTIVES

This study sought to evaluate the differences in the predictors of unsuccessful PCI in first-attempt CTO lesions of the 3 major coronary arteries compared with the J-CTO (Japanese CTO) score.

METHODS

This study assessed 6,408 first-attempt CTO patients from the Japanese CTO-PCI expert registry between January 2014 and December 2021, randomly assigned to derivation and validation sets. Difficulty scores for each artery were determined by assigning points to predictive unsuccessful factors.

RESULTS

The CTO lesions were distributed as follows: left anterior descending coronary artery: 2,245 (35%), left circumflex coronary artery: 1,131 (18%), and right coronary artery (RCA): 3,032 (47%). Regarding success rates, left circumflex coronary artery CTO had the lowest procedural success rate (90%) followed by RCA CTO (92%) and left anterior descending coronary artery CTO (94%). RCA CTO was significantly longer and more severely angulated, requiring more often the retrograde approach. A multivariate logistic analysis revealed that predictors of failed PCI were different in CTO lesions among the 3 major coronary arteries, respectively. Moreover, our difficulty score for RCA CTO was superior to the J-CTO score in predicting unsuccessful PCI.

CONCLUSIONS

Clinical and angiographic differences might explain the discrepancies of success rates in CTO lesions among the 3 major coronary arteries. Our novel difficulty score was comparable to the J-CTO score in predicting unsuccessful CTO-PCI with a superior discriminatory capacity.

A Novel Parallel Wire-based Antegrade Dissection Re-entry Technique for Failed Retrograde Attempt of Coronary Chronic Total Occlusions with Risk Nomogram Analysis

BACKGROUND

Rapid development in coronary chronic total occlusion (CTO) interventional techniques and devices have achieved a greater success rate with favorable outcomes. Antegrade dissection re-entry (ADR) technique is an important CTO crossing strategy and a desirable approach for long CTOs with good distal landing zone. However, unsuccessful procedures in contemporary CTO-percutaneous coronary intervention (PCI) remain, especially in lesions with non-interventional collaterals.

METHOD

Based on a single center experience, a hybrid interventional algorithm, parallel wire-based ADR (PW-ADR) combines the advantages of parallel wire technique (PWT) and device-based ADR to target CTO lesions with failed retrograde approach. A retrospective analysis of patients who underwent PW-ADR was performed. A risk nomogram was created to identify patients at high risk for technical failure.

RESULTS

A total of 57 patients treated with PW-ADR were ultimately included in the present study. A total of 46 (80.7%) cases achieved technical success and procedural success, with low incidence of in-hospital complications or 1-year major adverse cardiac events (MACE). The risk nomogram identified 3 predictor variables associated with technical failure of PW-ADR, including tortuous vessel, J-CTO score, and times of antegrade coronary angiography (CAG) during ADR, with promising accuracy (AUROC 0.947).

CONCLUSION

The novel hybrid CTO-PCI algorithm, PW-ADR, provided an alternative interventional approach for complex CTO lesions with a promising success rate. The risk nomogram served as a prompter for high-risk cases, which may warrant a change in treatment strategy.

Recanalisation of coronary chronic total occlusions

Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning. The contemporary procedural success rate is 80-90% with a reduction in complications. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. Despite this evidence, CTO recanalisation is grossly underutilised. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology.

Antegrade dissection and re-entry versus parallel wiring in chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry

BACKGROUND

The comparative efficacy and safety of parallel wiring versus antegrade dissection and re-entry (ADR) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is controversial.

METHODS

We compared the clinical and angiographic characteristics and outcomes of parallel wiring versus ADR after failed antegrade wiring in a large, multicenter CTO PCI registry.

RESULTS

A total of 1725 CTO PCI procedures with failed antegrade wiring with a single wire were approached with parallel wiring (692) or ADR (1033) at the discretion of the operator. ADR patients were older (65 ± 10 vs. 62 ± 10, years, p < 0.001) and had higher prevalence of comorbidities, such as diabetes mellitus (43% vs. 32%, p < 0.001), prior coronary artery bypass graft surgery (31% vs. 19%, p < 0.001), and lower left ventricular ejection fraction (50 ± 14 vs. 53 ± 11%, p < 0.001). The ADR group had higher J-CTO (2.8 ± 1.1 vs. 2.1 ± 1.3, p < 0.001) and PROGRESS-CTO (1.6 ± 1.1 vs. 1.2 ± 1.0, p < 0.001) scores. Equipment use including guidewires, balloons, and microcatheters was higher, and the procedures lasted longer in the ADR group. Technical success (78% vs. 75%, p = 0.046) and major adverse cardiovascular events (composite of all-cause mortality, stroke, acute myocardial infarction, emergency surgery or re-PCI, and pericardiocentesis) (3.7% vs. 1.9%, p = 0.029) were higher in the ADR group, with similar procedural success (75% vs. 73%, p = 0.166).

CONCLUSION

In lesions that could not be crossed with antegrade wiring, ADR was associated with higher technical but not procedural success, and also higher MACE compared with parallel wiring.

Absorbable Suture Embolization in Distal Coronary Perforation

Coronary artery perforation is a rare but serious complication during percutaneous coronary intervention. Distal or small vessel perforation is usually treated by coil, fat, or microsphere embolization. We describe 5 cases of distal coronary perforation that were managed successfully by a novel technique that uses absorbable sutures. (Level of Difficulty: Advanced.)

Global Chronic Total Occlusion Crossing Algorithm: JACC State-of-the-Art Review

The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.

[Technical armamentarium for chronic total occlusion of coronary vessels]

Percutaneous revascularization of chronic total occlusion (CTO) of coronary vessels represents a major challenge for contemporary interventional cardiologists. In the last decade there has been an unprecedented effort towards the standardization of revascularization procedures for CTO of coronary vessels. This endeavour has been possible by virtue of the growing interest of various cardiological societies for this patient group. Along with supportive endovascular technologies and percutaneous devices specifically dedicated to this interventional target, the increasing experience of interventionalists enabled continuously growing success for revascularization of CTO of coronary vessels. This review article highlights the currently available tools as well as technologies, techniques and strategies for the percutaneous recanalization of CTO of coronary vessels.

Retrograde Dissection and Reentry: Strategies: Common Pitfalls and Troubleshooting

The retrograde dissection reentry (RDR) technique is often required to treat the most complex chronic total occlusions (CTOs). This involves a sequence of procedural steps with many potential pitfalls. Procedural planning, knowledge of the equipment, including task-specific wires and microcatheters, and the ability to systematically trouble shoot is necessary to achieve consistent success. With the combination of more complex anatomy and collateral crossing, RDR is associated with higher rates of procedural complications, which the CTO operator must be specifically trained to avoid and to manage.

Technical Feasibility and Safety of Percutaneous Coronary Intervention for True Ostial Left Anterior Descending Artery-Chronic Total Occlusion

BACKGROUND

Percutaneous coronary intervention (PCI) for true ostial left anterior descending artery (LAD)-chronic total occlusion (CTO) lesions poses technical challenges owing to its inherent anatomic features.

METHODS

In total, 270 consecutive patients who underwent PCI for ostial LAD-CTO at 13 major cardiac centers in South Korea were included. Ostial LAD-CTO was strictly defined as a LAD-CTO lesion whose proximal cap was within 1 mm from the carina of the distal left main coronary artery (LMCA) bifurcation.

RESULTS

Ostial LAD-CTOs were frequently accompanied by stumpless lesion entry (43.4%), whereas significant bending within the occluded segment was less frequent (14.4%). The overall technical success rate was 85.9%, and serious in-hospital adverse events occurred in 5.6%. The retrograde approach tended to contribute more frequently to success in patients with concomitant LMCA disease, stumpless CTO, interventional collaterals, and higher Japanese-CTO scores. Apparent dissection or hematoma requiring rescue procedure at the LMCA or left circumflex artery occurred in 14 patients (5.2%), with a higher tendency in patients who had LMCA disease (12.1% vs 4.2%) and stumpless entry (9.4% vs 2.0%) than in those without. Among patients who were successfully treated, with an average of 1.7 stents, target-vessel failure occurred in 23 patients (9.9%) during a median 3.3 years of follow-up.

CONCLUSIONS

In this first large-scale analysis of true ostial LAD-CTO, PCI was feasible with a high technical success rate and favourable mid-term outcomes. Clinically relevant inflow vessel injury can occur during PCI and should be an important technical consideration regarding safety.

From reverse CART to antegrade wire access: a guide to externalisation, tip-in, rendezvous, and snaring from the APCTO club: Reverse CART to antegrade access

We at the Asia Pacific Chronic Total Occlusion (APCTO) club, provide this review to address the gap between reverse controlled antegrade and retrograde subintimal tracking (CART) and antegrade wire access. We describe the usual method for wire externalisation. We then address how to deal with failure to wire the proximal part of the chronic total occlusion (CTO) vessel or the guiding catheter. After successful antegrade guiding catheter wiring, we address the problem of failing to cross the CTO body with the retrograde microcatheter and we recommend the use of a retrograde small balloon, reversion to traditional CART, retrograde knuckle wiring into the subintimal space and antegrade scratch and go, and external cap crush. We also propose rendezvous type tip-in and describe the way to do this to overcome problems. In conclusion, we review and make recommendations for methods to gain antegrade wire access after successful reverse CART. We have addressed each failure mode in detail covering the different options, balancing risks and success rates. Our recommendations focus upon safety first and ease of use. We hope this work will help all retrograde operators to further improve the safety, efficacy, and success rates of their retrograde procedures.