Retrograde chronic total occlusion percutaneous coronary intervention via ipsilateral collaterals

BACKGROUND

There is limited data on retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) via ipsilateral epicardial collaterals (IEC).

AIMS

To compare the clinical and angiographic characteristics, and outcomes of retrograde CTO PCI via IEC versus other collaterals in a large multicenter registry.

METHODS

Observational cohort study from the Prospective Global registry for the study of Chronic Total Occlusion Intervention (PROGRESS-CTO).

RESULTS

Of 4466 retrograde cases performed between 2012 and 2023, crossing through IEC was attempted in 191 (4.3%) cases with 50% wiring success. The most common target vessel in the IEC group was the left circumflex (50%), in comparison to other retrograde cases, where the right coronary artery was most common (70%). The Japanese CTO score was similar between the two groups (3.13 ± 1.23 vs. 3.06 ± 1.06, p = 0.456); however, the IEC group had a higher Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score (1.95 ± 1.02 vs. 1.27 ± 0.92, p < 0.0001). The most used IEC guidewire was the SUOH 03 (39%), and the most frequently used microcatheter was the Caravel (43%). Dual injection was less common in IEC cases (66% vs. 89%, p < 0.0001). Technical (76% vs. 79%, p = 0.317) and procedural success rates (74% vs. 79%, p = 0.281) were not different between the two groups. However, IEC cases had a higher procedural complications rate (25.8% vs. 16.4%, p = 0.0008), including perforations (17.3% vs. 9.0%, p = 0.0001), pericardiocentesis (3.1% vs. 1.2%, p = 0.018), and dissection/thrombus of the donor vessel (3.7% vs. 1.2%, p = 0.002).

CONCLUSION

The use of IEC for retrograde CTO PCI was associated with similar technical and procedural success rates when compared with other retrograde cases, but higher incidence of periprocedural complications.

Retrograde Coronary Chronic Total Occlusion Intervention (JR-CTO) Score: From the Japanese CTO-PCI Expert Registry

BACKGROUND

Despite the effectiveness of the retrograde approach for chronic total occlusion (CTO) lesions, there are no standardized tools to predict the success of retrograde percutaneous coronary intervention (PCI).

OBJECTIVES

The objective of this study was to develop a prediction tool to identify CTO lesions that will achieve successful retrograde PCI.

METHODS

This study evaluated data from 2,374 patients who underwent primary retrograde CTO-PCI and were enrolled in the Japanese CTO-PCI Expert Registry between January 2016 and December 2022 (NCT01889459). All observations were randomly assigned to the derivation and validation cohorts at a 2:1 ratio. The prediction score for guidewire failure in retrograde CTO-PCI was determined by assigning 1 point for each factor and summing all accrued points.

RESULTS

The JR-CTO score (moderate-severe calcification, tortuosity, Werner collateral connection grade ≤1, and nonseptal collateral channel) demonstrated a C-statistic for guidewire failure of 0.72 (95% CI: 0.67-0.76) and 0.71 (95% CI: 0.64-0.77) in the derivation and validation cohorts, respectively. Patients with lower scores had higher guidewire and technical success rates and decreased guidewire crossing time and procedural time (P < 0.01).

CONCLUSIONS

The JR-CTO (Japanese Retrograde Chronic Total Occlusion) score, a simple 4-item score that predicts successful guidewire crossing in patients undergoing retrograde CTO-PCI, has the potential to support clinical decision-making for the retrograde approach.

Intracoronary snaring of the retrograde guidewire: A novel method to solve compartment mismatch in complex retrograde CTO PCI

The retrograde approach has allowed a remarkable improvement in the success rate of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). After collateral channel crossing, the most crucial aspect of retrograde CTO PCI is creating the connection between the antegrade and retrograde system. Currently, the most common technique to achieve this is reverse controlled antegrade and retrograde subintimal tracking. However, this maneuver sometimes fails due to compartment mismatch (intraplaque situation of one wire and extraplaque situation of the other). New approaches are therefore needed to overcome challenges in this important step of the procedure. Here we present an innovative solution to this problem, which involved capturing the retrograde guidewire (advanced into a side branch at the distal cap) with a microsnare that had been advanced antegradely: this severed the dissection flap separating the antegrade and retrograde system, thus allowing us to successfully recanalize the CTO.

Arterial embolization via retrograde approach using steerable microcatheter and triaxial system

We report a case of postoperative pseudoaneurysm, successfully treated with selective arterial embolization, using a steerable microcatheter and triaxial system via retrograde approach. A pseudoaneurysm was detected in the dorsal pancreatic artery, a severely narrow and steeply inverted branch of the superior mesenteric artery, making microcatheter insertion via the antegrade approach challenging. However, a steerable microcatheter was advanced beyond the orifice and the tip was reversed, changing the route to retrograde allowing for easy insertion of the microguidewire. Subsequently, a small microcatheter was advanced beyond the pseudoaneurysm into the dorsal pancreatic artery, and arterial embolization was successfully completed without complications.

Retrograde balloon hemostasis

Despite improvements in current devices and techniques for complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI), procedural complications, including coronary perforation, still occur and could be life-threatening. A patient with a history of multivessel coronary artery disease and a CTO of the right coronary artery (RCA) underwent successful retrograde crossing of an RCA CTO. After wiring the CTO body and lesion dilatation, a drug-eluting stent was implanted in the distal RCA toward the posterior descending artery. A large Ellis type III perforation occurred at the distal edge of the stent. Septal crossing with a balloon and tamponade of the perforation site through the retrograde collaterals followed, as the RCA was not suitable to accommodate easily both the covered stent and the balloon simultaneously. This case report presents a novel approach the "septal retrograde ping-pong" technique, which demonstrates successful treatment of coronary perforations by utilizing a retrograde approach through a septal collateral. This technique proves to be effective in situations where the conventional antegrade balloon or covered stent delivery methods are not feasible or unsuccessful. This innovative approach offers a promising alternative for managing challenging cases of coronary perforations, providing new insights and potential solutions for interventional cardiologists.

Antegrade Crossing Techniques for Hard Proximal Occlusion Caps Without the Use of Dedicated Chronic Total Occlusion Devices: A Pictorial Review

CLINICAL IMPACT

Infra-inguinal Chronic Total Occlusions recanalisation is considered technically challenging. The conventional manipulation of standard guidewires and catheters has proven to be successful in a considerable percentage of cases but success rate could dramatically drop in presence of challenging lesions. The additional use of retrograde access and re-entry devices could increase technical success but could negatively affect procedural time and overall costs. Twenty different techniques of Chronic Total Occlusions antegrade crossing are hereby described with appropriate schematic representations. The aim is to help operators to apply them in specific anatomy subsets and clinical presentations and ultimately to increase procedural success rate.

Retrograde percutaneous coronary intervention of chronic total occlusion via discontinuous septal channels

OBJECTIVES

The study aims to investigate the safety and feasibility of retrograde CTO intervention via collateral connection grade 0 (CC-0) septal channel and to identify predictors of collateral tracking failure.

BACKGROUND

Guidewire crossing a collateral channel is a critical step for successful retrograde percutaneous coronary intervention (PCI) of chronic total occlusion (CTO).

METHODS

Retrograde PCI was attempted in 122 cases of CTO with CC-0 septal collaterals from December 2018 to May 2021. A hydrophilic polymer coating guidewire was used for crossing all intended CC-0 collaterals. A multivariable logistic regression analysis was performed to identify the predictors of guidewire tracking failure via the CC-0 collaterals.

RESULTS

Successful guidewire tracking via CC-0 septal channel was achieved in 98 (80.3%) of 122 cases. The independent predictors of CC-0 septal channel guidewire tracking failure included well-developed non-septal collateral (OR: 5.297, 95% CI: 1.107-25.353, p = 0.037) and the ratio length of posterior descending artery (PDA) versus the distance of PDA ostium to cardiac apex ≤2/3 (OR: 3.970, 95% CI: 1.454-10.835, p = 0.007). Collateral perforation, target vessel perforation, and cardiac tamponade occurred in 5 (4.1%), 3 (2.5%), and 6 (4.9%) cases, respectively. There were no complications requiring emergency cardiac surgery or revascularization of nontarget vessel.

CONCLUSIONS

Retrograde PCI via CC-0 septal channels with a hydrophilic polymer-coated guidewire is feasible and safe in patients with CTO. Well-developed nonseptal collaterals and short PDA length influence the procedure success and the risk of guidewire tracking failure via CC-0 septal channels.

Realignment of Migrated Celiac Stent Graft After Branched Stent Graft Implantation Through Retrograde Cannulation of the Superior Mesenteric Artery Using a Single Vascular Access

PURPOSE

The purpose of the study was to present an endovascular management of a type IIIc endoleak (EL) in a patient with migration of the bridging stent graft of the celiac trunk (CT) after branched aortic aneurysm repair with retrograde cannulation of the superior mesenteric artery (SMA).

TECHNIQUE

The therapy was applied in a 62-year-old man who underwent a branched EVAR 2 years ago. Meanwhile, the patient was treated due to type Ia EL 6 months ago. The patient suffered in the last days from unclear hemorrhage clinically correlated with weakness. In the computed tomography angiography (CTA), an EL IIIc with a migration of the bridging stent graft from the CT branch was displayed. As vascular access, the left axillar artery was used. Due to the misaligned bridging stent graft, an antegrade cannulation was impossible, so cannulation was performed retrograde through the SMA using pancreaticoduodenal and gastroduodenal arteries. Thereafter, the EL could be repaired with bridging stent grafts. The postinterventional control showed a satisfying reconstruction without EL or embolization.

CONCLUSION

Most of the complications such as type IIIc EL after complex endovascular repair can also be treated endovascularly. This sophisticated treatment requires that necessary materials and experience are available.

Role of the retrograde Carlino technique for chronic total occlusion percutaneous coronary intervention

BACKGROUND

There is scarce data on the outcomes of the Carlino technique for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to investigate the indications and outcomes of the Carlino technique as performed in the context of the retrograde approach.

METHODS

We pooled CTO PCI cases where a retrograde Carlino technique was performed from high-volume operators at four centers. The Carlino technique was characterized according to its indication (achieving plaque/cap modification, clarifying microcatheter location within the vessel, resolving distal cap ambiguity) and was considered successful when it led to the desired outcome.

RESULTS

A total of 43 patients were included. Occlusion complexity was very high (mean J-CTO score 3.3 ± 0.8). The two most common indications were understanding the anatomy of the occlusion and clarifying gear location (37.2%) and impenetrable distal cap (34.9%). The Carlino technique was successful in 88.4% of cases. Overall technical and procedural success was 86.0%. The most common successful crossing technique was reverse controlled antegrade and retrograde subintimal tracking (70.3%). No complications were attributed to the Carlino technique.

CONCLUSIONS

We observed a high success rate of the retrograde Carlino technique, as well as overall technical and procedural success rates. No Carlino technique-related complications were observed. Additional data from larger registries are warranted to further confirm the safety and efficacy of this technique.

Primary vs Secondary Retrograde Approach in Chronic Total Occlusion Percutaneous Coronary Interventions

BACKGROUND

The retrograde approach to coronary chronic total occlusions (CTOs) can be used as the initial crossing strategy (primary retrograde) or after failure of antegrade crossing attempts (secondary retrograde).

METHODS

We compared baseline clinical and angiographic characteristics and procedural outcomes of primary vs secondary retrograde crossing for CTO percutaneous coronary intervention (PCI) among 2789 procedures performed at 34 centers between 2012 and 2021.

RESULTS

Retrograde CTO-PCI was performed as the primary crossing strategy in 1086 cases (38.9%) and as a secondary approach in 1703 cases (61.1%). Patients in the primary group had slightly lower left ventricular ejection fraction (49.1% vs 50.4%; P=.02), were more likely to have had prior coronary artery bypass graft surgery (52.9% vs 38.4%; P&lt;.001), and had higher J-CTO (3.31 ± 0.98 vs 2.99 ± 1.09; P&lt;.001) and PROGRESS-CTO scores (1.47 ± 0.92 vs 1.29 ± 0.99; P&lt;.001). Technical (81.4% vs 77.3%; P=.01) and procedural success rates (78.6% vs 74.1%; P&lt;.01) were higher in the primary retrograde group, with no difference between in-hospital major adverse event rates (4.3% vs 4.0%; P=.66). Contrast volume (250 mL [interquartile range (IQR), 176-347] vs 270 mL [IQR, 190-367]; P&lt;.001) and procedure time (175 minutes [IQR, 127-233] vs 180 minutes [IQR, 142-236]; P&lt;.001) were lower in the primary group.

CONCLUSIONS

Use of retrograde approach as the primary crossing strategy is associated with higher rates of technical and procedural success and similar rates of in-hospital major adverse cardiac events compared with secondary retrograde CTO-PCI.

A retrograde approach for transcatheter valvotomy procedure in infants with pulmonary atresia intact ventricular septum (PA-IVS): retrograde versus antegrade approach

INTRODUCTION

This study evaluates the retrograde approach compared to the antegrade approach in infants with PA-IVS who underwent transcatheter pulmonary valvotomy procedure at National Cardiovascular Center Harapan Kita, Jakarta, Indonesia.

MATERIAL AND METHOD

This is a single-centre retrospective study conducted from January 2017 to June 2019 consisting of infants undergoing transcatheter pulmonary valvotomy procedures from our centre.

RESULTS

Among 3733 records of cardiac catheter procedure in paediatric patients during the last 3 years, there were 12 subjects with PA-IVS, where five subjects were done by antegrade approach and seven by retrograde approach. The retrograde approach is shown to excel the antegrade approach in terms of procedural time by 58.64 minutes (CI 95 % 32.97-84.29, p = 0.008) and PA-RV crossing time by 27 minutes (CI 95 % 14.01-39.99, p = 0.02). There was no significant difference in contrast used (120.23 ± 25.77 versus 150.27 ± 39.26 ml/BSA, p = 0.518), and right ventricle to pulmonary artery systolic pressure gradient after valvotomy (39.571 ± 5.814 versus 53.52 ± 29.15, p = 0.329) between the retrograde and the antegrade approach.

CONCLUSION

The retrograde approach offered shorter procedural time and comparably satisfying results than the antegrade approach. The shorter procedural time was preferred due to the shorter duration of general anaesthesia, which may decrease the risk of neurodevelopmental deficits in the patient.

Angiographic Predictors of Septal Collateral Tracking During Retrograde Percutaneous Coronary Intervention for Chronic Total Occlusion: Anatomical Analysis or Rolling the Dice?

OBJECTIVES

The aim of this study was to identify independent angiographic predictors of collateral channel (CC) tracking success, microcatheter tracking failure, and complications in chronic total occlusion (CTO) retrograde approach. We also developed a "crossability score," comparing its predictive performance with pre-existing scores.

BACKGROUND

The retrograde approach was introduced for recanalization of challenging CTOs. The passage of guidewires through CCs is a key step of the procedure. Two scoring systems have been recently developed to predict CC tracking success.

METHODS

A total of 180 patients and 297 CCs were retrospectively analyzed in an unselected retrograde CTO population.

RESULTS

Guidewire crossing was successful in 203 collaterals (68.3%). The only independent predictor of successful CC tracking was Werner score 2. Conversely, Werner score 0, severe tortuosity (>180°), acute exit angle (<90°), and length of collateral were independently associated with tracking failure. We assigned a score to each "significant" variable to create a model that showed a greater accuracy than pre-existing scores (area under the receiver-operator characteristics curve, 0.72 vs 0.65 and 0.69). Moreover, CC length was also associated with microcatheter tracking failure and complications.

CONCLUSIONS

Werner score 0, tortuosity, acute exit angle, and CC length were independently associated with CC tracking failure, whereas Werner score 2 was a predictor of crossing success. Length of CC is associated with a higher rate of microcatheter crossing failure and complications. We combined these findings into the R-ICPS score, which showed an adequate accuracy for collateral crossing prediction.

Temporal Trends in Retrograde Crossing of Epicardial Collaterals in Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND

The use of retrograde crossings in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) provides higher technical success rates in CTO-PCI. However, the use of epicardial collaterals carries a higher complication risk.

METHODS AND RESULTS

In this study, we aimed to investigate the temporal trends in retrograde crossing of epicardial collaterals, introduction of new guidewires, in-hospital major adverse cardiovascular events (MACE), and technical success rates in a large, multinational registry. We demonstrate that technical success rates increased substantially from about 5%-10% to 76% in the past decade without a concomitant increase in MACE rate (~3% to 4%), likely associated with increased operator experience and introduction of new guidewires. In addition, we show that while high-volume centers have higher technical success, they also have higher perforation rates.

Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I ² statistic. Subgroup and sensitivity analyses were also performed. Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, p = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. Systematic Review Registration: "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.

Retrograde Recanalization of Occluded Radial Artery: A Single-Centre Experience and Literature Review

PURPOSE

Radial artery occlusion (RAO) is one of the common complications after coronary intervention via the conventional radial artery approach. The purpose of the study was to explore the safety and feasibility of retrograde recanalization of the occluded radial artery via a distal radial artery (DRA) approach.

METHODS

Combined with the practice of our centre and a literature review, we summarized the procedure of retrograde recanalization of RAO, success rate, and complications.

RESULTS

A total of 14 of 15 patients with 15 pieces of occluded radial arteries were successfully recanalized via the DRA in our centre. In the 15 occluded vessels, 11 vessels (73.3%) had total occlusion and 4 vessels (26.7%) had functional occlusion. Four of 15 occluded vessels were acute occlusions. Two acute RAOs were only treated with aspiration via sheath, 11 RAOs with balloon angioplasty, and 2 RAOs with both, respectively. In 6 patients, cardiac catheterization was carried out via the DRA after recanalizing the RAO. A total of 10 studies reporting the results of recanalization of RAO via the DRA were systematically retrieved in the present study. In 3 case series, the number of cases was more than 5, and the success rate of recanalization was more than 85.7%. Two studies reported complications, including dissection in one case, hematoma in 2 cases, and pain in the forearm during angioplasty.

CONCLUSIONS

Recanalization of the occluded radial artery via the DRA was safe and effective. When repeat cardiac catheterization was required, recanalization of the RAO and subsequent coronary angiography or intervention through the ipsilateral radial artery approach was feasible.

Patent Ductus Arteriosus Device Closure in Interrupted Inferior Vena Cava: Challenges Overcome and Lessons Learnt: A Case Series

Interrupted inferior vena cava (IVC) with azygous continuation provides technical challenge in many percutaneous cardiac interventions. They are performed via the femoral venous access route. We describe four such cases in whom, patent ductus arteriosus (PDA) device closure was done in interrupted IVC. All the four cases were done using the femoral route. Two cases were done via retrograde approach through femoral artery access, in which one was closed with a muscular VSD device and the other with a Gianturco coil.

The introduction of newer closure devices helps in the retrograde approach. Two cases were done via anterograde approach through the femoral venous route, with a loop through the azygous vein. One child had transient bradycardia due to cardiac stretch which normalized after the device deployment and introducer system removal.

Thus, we describe different femoral approaches in interrupted IVC patients for PDA closure, with the difficulties faced and the complications managed.

Case Report: Transcatheter Closure of Ruptured Sinus of Valsalva With Ventricular Septal Defect Occluder in a 3-Year-Old Child After Repair of Ventricular Septal Defect

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that can undergo spontaneous rupture into other cardiac chambers or the pericardial space. A ruptured SVA has a very poor prognosis with high morbidity and mortality. These aneurysms often present as a rupture from the right coronary sinus into the right ventricle. Transcatheter closure has become an effective alternative to surgical treatment. However, it has been rarely reported in patients after ventricular defect repair in the past. We here describe a 3-year-and-3-month-old boy who was found to have a ruptured sinus of Valsalva. He underwent surgical closure of a ventricular septal defect at the age of 2 months, which occurred in the non-coronary sinus (NCS) and ruptured into the right atrium. We successfully occluded the ruptured sinus of Valsalva with a ventricular septal occluder.

Trans-popliteal hybrid retrograde technique for revascularization of chronic total occlusions of the superficial femoral artery

OBJECTIVES

We present the technical description and preliminary results of a hybrid approach for the treatment of chronic total occlusions of superficial femoral artery in the setting of critical limb-threatening ischemia (CLTI).

METHODS

A retrospective analysis of selected case series was performed. A trans-popliteal hybrid technique was carried out in seven limbs (six patients). Open exposure of above-the-knee popliteal artery was performed over its maximum calcification zone. After retrograde recanalization and graft-stenting of the entire superficial femoral artery, endarterectomy of the popliteal artery was performed for debulking and widening of the distal landing zone of the endoprosthesis. The latter is included in the bovine patch suture to avoid leaving a segment untreated.

RESULTS

Technical success, haemodynamic and clinical improvement were achieved in all procedures. Median length of treated occlusion was 19.8 cm. After a mean follow-up of 12 months (range 6-26 months), the primary patency was 85.7% (only one asymptomatic occlusion occurred). There were no major cardiovascular or limb adverse events. No re-interventions were required.

CONCLUSION

This less-invasive, one-incision technique is safe and effective for the restoration of in-line flow from groin to ankle, currently recommended in CLTI revascularization. It could be especially useful in highly calcified popliteal artery lesions, hostile groins or those at high risk of infection and in cases of vein absence for bypass surgery.

Removal of an encrusted ureteral stent by cutting the stent with a holmium laser using 4.5-Fr semi-rigid and flexible ureteroscopes

INTRODUCTION

Ureteral stents (double-J stents) are widely used in urology to prevent or relieve ureteral obstruction and have become an integral part of urological practice. We have often experienced cases in which a stent cannot be removed due to encrustation.

CASE PRESENTATION

We describe the case of a 54-year-old male, who presented with a severely encrusted ureteral stent, which had only been inserted for one month until second surgery for renal stones. The ureteral stent could not be removed as it had become encrusted with renal stones. The encrusted ureteral stent was successfully removed by cutting it with a Ho:YAG laser using 4.5/6.5-Fr semi-rigid and flexible ureteroscopes retrogradely. The patient subsequently remained stone-free without any complication.

CONCLUSION

We experienced a case in which an encrusted ureteral stent was successfully removed retrogradely. Technological advancements in endourology will hopefully make the treatment of such cases safer and less invasive.

Experimental Analysis of Intra-luminal Pressure by Contrast Injection during Mechanical Thrombectomy: Simulation of Rupture Risk of Hidden Cerebral Aneurysm in Tandem Occlusion with Blind Alley

Mechanical thrombectomy using a retrograde approach is performed for tandem occlusion of the internal carotid artery (ICA). In our patient, a guiding catheter was easily passed by the stenosed lesion despite severe stenosis at the ICA origin. Therefore, we aimed to recanalize the occlusion of the terminal ICA without angioplasty for the stenosed lesion. When contrast was injected, a massive extravasation of contrast from the C2 portion of the ICA was observed. It was speculated that the bleeding was caused by rupture of an aneurysm at that site due to increased intra-arterial pressure caused by the contrast injection to a blind alley, which was created by a wedged guiding catheter at severe stenosis at the ICA origin and the occlusion of the terminal ICA. Our simulation experiment using a silicon vascular model in this situation demonstrated that the elevation of intra-arterial pressure in such blind alley reached over 50, 100, and 200 mmHg by injection of contrast from a microcatheter, a 4-Fr inner catheter, and a 9-Fr balloon-guiding catheter, respectively. When a retrograde approach is planned for tandem occlusion of the ICA, even when the proximal lesion is easily passed, prior angioplasty for the proximal lesion should be considered to avoid wedging by catheter.

Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Intervention

The retrograde approach has increased the success rate of chronic total occlusion percutaneous coronary intervention but has also been associated with a higher risk of complications. The retrograde approach is usually performed in complex lesions, in which the antegrade approach is not feasible or has failed previously. Using a systematic 10-step approach can maximize the likelihood of success and minimize the risks of retrograde chronic total occlusion interventions.

Antegrade Versus Retrograde Technique for Fixation of Scaphoid Waist Fractures: A Comparison of Screw Placement

Background  Scaphoid waist fractures are often treated using headless compression screws using dorsal or volar approaches. Objectives  The purpose of this study is to compare differences in screw position using a volar (retrograde) or dorsal (antegrade) approach. Patients and Methods  A total of 82 patients were retrospectively evaluated: 41 treated with a volar and 41 with a dorsal approach were selected. Postoperative radiographs were reviewed by three observers who rated screw location in the proximal pole, waist, and distal pole. Results  Thirty-four patients (83%) in the antegrade group had central screw placement in the waist of the scaphoid in posteroanterior and lateral planes compared with 14 (34.9%) in the retrograde group ( p  < 0.05). For the antegrade group, the screw was central in 217 of 246 zones (88.2%) compared with 127 of 246 (51.6%) in the retrograde group ( p  < 0.05). Conclusions  The dorsal antegrade approach appears to allow the surgeon to achieve central screw placement along all three scaphoid regions. Level of Evidence  This is Level III study.

PBPK in Preterm and Term Neonates: A Review

INTRODUCTION

The neonatal population remains one of the populations in which appropriate dosing regimens are still lacking, resulting in a large off-label or unlicensed use. Clinical research in these small infants remains a challenge, which sparks the need for modeling and simulation as an additional tool for neonatal drug research.

METHODS

The use of physiologically based pharmacokinetic modeling in preterm and term neonates is investigated.

RESULTS

Throughout the last decade, the use of this modeling technique in this vulnerable population has received increased attention, but still many knowledge gaps exist. Firstly, an overview of the top-down, bottom-up and middle-out approach is given, and then these different modeling tools regarding feasibility and appropriate use are compared. The challenges in applying PBPK to this young population are highlighted and possible solutions are presented. Examples of applications were found in literature and a preference for the combination of a pure bottom- up approach with clinical data (the "middle-out" approach) was detected.

CONCLUSION

Perspectives to further apply this powerful modeling methodology in this population are described in order to become 'the tool' for the design of First-in-Human and First-in-Neonate trials, and the individualization of dosing in these therapeutic orphans.

Comparison Between Traditional and Guide-Catheter Extension Reverse Controlled Antegrade Dissection and Retrograde Tracking: Insights From the PROGRESS-CTO Registry

OBJECTIVES

The most common re-entry technique during retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is reverse controlled antegrade and retrograde tracking (rCART). The use of guide-catheter extensions can facilitate rCART, but has received limited study.

METHODS

We compared the clinical and procedural characteristics and outcomes of traditional rCART vs guide-catheter extension rCART vs cases in which both techniques were used (combined rCART) in patients with successful retrograde CTO crossing in a contemporary multicenter CTO-PCI registry.

RESULTS

Between 2012 and 2018, rCART was used in 467 of 1336 retrograde CTO-PCI cases. Guide-catheter extension rCART was used in 60/467 cases (13%; use increased from 0% in 2012 to 26% in 2017). The traditional rCART group, guide-catheter extension rCART group, and combined rCART group had similar target lesion J-CTO scores (3.3 ± 1.1 vs 3.2 ± 1.2 vs 3.6 ± 0.8, respectively; P=.28), technical success rates (99% vs 100% vs 96.4%, respectively; P=.36), procedural success rates (93.2% vs 93.8% vs 96.3%, respectively; P=.82), and major in-hospital adverse cardiac event (MACE) rates (6.4% vs 9.4% vs 3.6%, respectively; P=.66). Total procedural time was longer in the combined rCART group (196 min [IQR, 146-256 min] vs 200 min [IQR, 164-293 min] vs 255 min [IQR, 195-280 min], respectively; P<.01), with a trend for lower patient air kerma radiation dose in the guide-catheter extension groups (4.11 Gray [IQR, 2.49-5.77 Gray] vs 3.19 Gray [IQR, 1.29-4.74 Gray] vs 3.47 Gray [IQR, 2.89-5.56 Gray]; P=.07).

CONCLUSIONS

Guide-catheter extension rCART is increasingly being used for retrograde CTO crossing and is associated with similar success and MACE rates as traditional rCART.

Technique to Facilitate Retrograde Puncture of Mid to Upper Calf Tibial Vessels

PURPOSE

To describe a simple maneuver to facilitate the retrograde puncture of challenging tibial vessels in the lower leg.

TECHNIQUE

Because of the depth of the tibial vessels at the mid to upper calf, especially in obese or muscular patients, a 7- or 9-cm, 21-G micropuncture needle is often needed to reach the artery. However, the low profile of the needle contributes to its flexibility and therefore the tendency to bend as it progresses through the deep tissues, hindering access to the target vessel. To overcome this obstacle, a 4- to 5-cm, 18-G needle is initially placed pointing to the artery. The 21-G needle is advanced through it to the target site. This simple maneuver increases the support to the 21-G needle, preventing its bending and facilitating arterial puncture in the presence of calcified vessels.

CONCLUSION

The telescoping needle technique may be considered as a bailout procedure in the retrograde tibial approach after failed attempts secondary to needle bending or calcified vessels.

Below-the-Knee Retrograde Access for Peripheral Interventions: A Systematic Review

PURPOSE

To investigate the hypothesis that interventions involving retrograde below-the-knee (BTK) vessel punctures have an acceptably low complication rate and high procedural success.

METHODS

A systematic review was performed of the MEDLINE and Scopus databases for articles describing the results of BTK retrograde access for peripheral interventions. Outcome measures were access success, procedure success, and complications. A predefined subgroup analysis was performed of prospective studies to reduce the influence of possible reporting bias on outcomes.

RESULTS

Nineteen articles, including 3 prospective studies, were selected, including a total of 1905 interventions in 1395 patients (mean age 69.5 years; 918 men). The BTK vessels were punctured in 1168 (61.3%) of these interventions. Access was successful in 94.0% of BTK attempts, 86.0% of all lesions were successfully crossed using a retrograde access, and 84.0% of interventions achieved technical success. Forty-eight (4.1%) distal access site complications were reported. Vessel perforations were seen in 13 (1.1%) interventions, vasospasm in 5 (0.4%), and acute distal occlusions in 5 (0.4%). Predefined subgroup analysis of prospective studies showed similar results (p=0.24).

CONCLUSION

A retrograde approach to facilitate peripheral endovascular interventions is a safe and successful technique and should be considered when an antegrade approach is not possible or fails to cross the lesion. Because of missing data on long-term outcomes and methodological shortcomings, real world data of retrograde access in nonexpert centers remains necessary before this technique can be advised to all interventionists dealing with peripheral artery disease.

Epicardial collateral channel for retrograded recanalization of chronic total occlusion percutaneous coronary intervention: Predictors of failure and procedural outcome

OBJECTIVES

This study set out to identify significant lesion features of chronic total occlusion (CTO) that predict successful retrograde recanalization via epicardial collateral channels (CCs).

BACKGROUND

Epicardial CCs remain essential in retrograde percutaneous coronary intervention (PCI) of CTO. However, the unpredictability of success and occurrence of complications limit the application of epicardial CCs for retrograde PCI technique for CTO.

METHODS

103 retro-recanalization cases were analyzed using epicardial CCs with successful recanalization as an end point. Clinical and angiography data were collected.

RESULTS

The total success rate was 76.3%. Independent predictors associated with technical success included CCs tortuosity, side branch at CCs tortuosity, inadequate CCs Size and inadequate CCs exit location. Assigning a score of one for each variable, four levels of difficulty were obtained and formed the EPI-CTO score (Epicardial CTO). This score had significant predictive value for the likelihood of successful recanalization (AUC: 0.94, 95%CI: 0.89-0.98). Coronary and CCs perforation occurred in 6 and 10 cases respectively. Four cases including two coronary and two CCs perforations had tamponade that needed pericardiocentesis.

CONCLUSIONS

Using epicardial CCs for retrograde approach of CTO PCI is effective. Complication rate was acceptable. We found four independent predictors relative to procedure success.

The trap and occlude technique for retrograde wire externalization during chronic total occlusion revascularization

Different strategies of retrograde approach were introduced in recent years to improve the success rate of percutaneous coronary intervention for coronary chronic total occlusions. The aim of this report is to describe a new technique, called "Trap and Occlude Technique," for retrograde wire externalization during CTO percutaneous revascularization. This technique may save time and reduce radiation exposure and procedure-related bleeding.

Retrograde Approach Using Surgical Cutdown Technique for Limb Salvage in a Case of Critical Limb Ischemia With Severely Calcified Tibial Occlusive Disease

We here report a successful angioplasty for tibial artery occlusion using direct tibial puncture and subsequent retrograde approach under surgical cutdown technique. An 82-year-old man with ulcer/gangrene in first and second digits was referred to our hospital for endovascular therapy (EVT) of lower extremity ischemia. Diagnostic angiogram revealed anterior tibial artery (ATA) occlusion with severe calcification. Subintimal angioplasty was attempted using a 0.014-inch hydrophilic guidewire but was unsuccessful. A retrograde approach was subsequently attempted for ATA recanalization. However, because of severe calcification of dorsal pedis artery (DPA), percutaneous distal puncture was also unsuccessful. Direct puncture under surgical cutdown technique for DPA was subsequently performed and was successful. A 0.014-inch hydrophilic wire was advanced in retrograde fashion across the ATA occlusion and was used to access the microcatheter positioned at the proximal ATA via antegrade approach. Angioplasty of the ATA occlusion was performed using a 2.5-/3.0-mm tapered balloon. Completion angiogram revealed restoration of flow without dissection. Skin perfusion pressure was dramatically improved. Complete wound healing was achieved 5 months after EVT.

Tibiopedal Access for Crossing of Infrainguinal Artery Occlusions: A Prospective Multicenter Observational Study

Purpose: To report a prospective, multicenter, observational study (ClinicalTrials.gov identifier NCT01609621) of the safety and effectiveness of tibiopedal access and retrograde crossing in the treatment of infrainguinal chronic total occlusions (CTOs). Methods: Twelve sites around the world prospectively enrolled 197 patients (mean age 71±11 years, range 41-93; 129 men) from May 2012 to July 2013 who met the inclusion criterion of at least one CTO for which a retrograde crossing procedure was planned or became necessary. The population consisted of 64 (32.5%) claudicants (Rutherford categories 2/3) and 133 (67.5%) patients with critical limb ischemia (Rutherford category ≥4). A primary antegrade attempt to cross had been made prior to the tibiopedal attempt in 132 (67.0%) cases. Techniques used for access, retrograde lesion crossing, and treatment were at the operator’s discretion. Follow-up data were obtained 30 days after the procedure. Results: Technical tibiopedal access success was achieved in 184 (93.4%) of 197 patients and technical occlusion crossing success in 157 (85.3%) of the 184 successful tibial accesses. Failed access attempts were more common in women (9 of 13 failures). The rate of successful crossing was roughly equivalent between sexes [84.7% (50/59) women compared to 85.6% (107/125) men]. Technical success did not differ significantly based on a prior failed antegrade attempt: the access success rate was 92.4% (122/132) after a failed antegrade access vs 95.4% (62/65) in those with a primary tibiopedal attempt (p=0.55). Similarly, crossing success was achieved in 82.8% (101/122) after a failed antegrade access vs 90.3% (56/62) for patients with no prior antegrade attempt (p=0.19). Minor complications related to the access site occurred in 11 (5.6%) cases; no patient had access vessel thrombosis, compartment syndrome, or surgical revascularization. Conclusion: Tibiopedal access appears to be safe and can be used effectively for the crossing of infrainguinal lesions in patients with severe lower limb ischemia.

Retrograde Coronary Chronic Total Occlusion Intervention

Coronary chronic total occlusion (CTO) is a frequent finding in patients with coronary artery disease. It remains one of the most challenging subsets, accounting for 10-20% of all percutaneous coronary interventions (PCI). Although remarkable progress in PCI has been made, it is reasonable to state that successful recanalization of CTO represents the “last frontier" of PCI. PCI of CTOs has been limited historically by technical success rates of 50-70%. The introduction of enhanced guidewires, microcatheter, channel dilatator with increasing operator experience, and innovative techniques such as the retrograde approach have raised hopes for better outcomes. This article goes into depth into various strategies of retrograde approach in CTO.

Popliteal Retrograde Approach is Effective and Safe for Superficial Femoral Artery Chronic Total Occlusion

OBJECTIVE

Endovascular treatment (EVT) using a popliteal approach is effective for superficial femoral artery (SFA) chronic total occlusion (CTO); however, its effectiveness, safety, and consequent complications are unclear.

MATERIALS AND METHODS

We studied 324 consecutive EVTs (in 187 patients) performed at three centers between April 2008 and March 2013, and selected all EVTs that included SFA CTO regions. A total of 91 EVTs (in 65 patients) were included and divided into two groups; "with popliteal approach" (WPA) and "without popliteal approach" (WOPA).

RESULTS

Despite higher rates of hypertension (WPA, 88.9% vs. WOPA, 69.1%; p = 0.04) and CTO length >200 mm (55.6% vs. 28.3%, respectively; p <0.01), the primary success rate was better in the WPA group (97.2% vs. 78.2%, respectively; p <0.01); however, both total complication rate and major complication rate were not significantly different. We compared popliteal puncture using a sheath and using a microcatheter alone. There were no significant differences between sheath and microcatheter use in terms of primary success rates (95.5% vs. 100%, respectively; p = 0.61) and puncture site complications (22.7% vs. 14.2%, respectively; p = 0.53).

CONCLUSION

A popliteal approach improved the primary success rate of EVT for SFA CTO.

Transcatheter closure of ruptured sinus of Valsalva: Different techniques and mid-term follow-up

OBJECTIVES

The aim of the present study was to study the feasibility and approaches to device closure of ruptured sinus of Valsalva (RSOV). We have compared the advantages and disadvantages of different devices and techniques and discussed complications which might occur during or after the procedure.

BACKGROUND

There are only a few case series of transcatheter closure of RSOV, with most cases being traditionally referred for surgery. We have employed different devices used for treatment of congenital shunt lesions to achieve closure. Reasons for failure and need for surgical referral have also been analyzed.

METHODS

Transcatheter closure was attempted in a total of 25 patients of RSOV who presented to us over a period of 4 years. Different devices were deployed using antegrade and retrograde approaches. All patients have been on regular follow-up.

RESULTS

The procedural success rate was 84%. Two patients presenting in cardiogenic shock were effectively treated by device closure. There was one case of device embolization and two patients had residual leak. Three patients were referred for surgery. There was one case of device induced severe aortic regurgitation. Ventricular septal defect and RSOV were closed simultaneously in one patient.

CONCLUSIONS

Different approaches and devices may be used for transcatheter closure of RSOV. We prefer antegrade closure using duct occluders in most cases while muscular VSD occluders may be used in select situations. ADO II devices should hardly ever be used on their own for device closure of RSOV.

Amplatzer duct occluder II for closure of congenital Gerbode defects

BACKGROUND

Congenital left ventricle to right atrial communications (Gerbode defects) are extremely rare (0.08%) type of ventricular septal defects. They were traditionally closed by surgery in the past. There are few case reports and small series of acquired and congenital Gerbode defects, closed with various types of devices. Aim of our study is to assess the feasibility, efficacy, and complications of transcatheter closure of congenital Gerbode defects with Amplatzer duct occluder II (ADO II).

MATERIAL

Twelve consecutive cases of Gerbode defects, age ranging from 10 months to 16 years (mean 6.7 years), weight ranging from 6.5 kg to 34 kg (mean 19.3 kg), were diagnosed on transthoracic echocardiography.

RESULTS

Transcatheter closure of Gerbode defects was done successfully through retrograde approach with ADO II. No aortic or tricuspid regurgitation or residual shunt occurred in any of the patients. One patient developed transient complete heart block needing temporary pacing.

DISCUSSION

The soft low profile, easily trackable ADO II appears to be ideal for closure of Gerbode defects, as the central cylinder fits in the defect and the soft retention discs on either side, without polyester material, do not impinge on either aortic, mitral, or tricuspid valve. We report the successful transcatheter closure of twelve cases of congenital Gerbode defects with ADO II.

CONCLUSIONS

Transcatheter closure of congenital Gerbode defects with ADO II is safe, effective, and an attractive alternative to surgical closure. ADO II appears to be tailor made for Gerbode defects, as the success rate is very high and complication rate is very low.

New Advances in Chronic Total Occlusions

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.

Successful bypass restenting across the struts of an occluded subintimal stent in chronic total occlusion using a retrograde approach

Recently, subintimal angioplasty has been introduced as a bailout strategy to improve the success rate of PCI for vessels with CTO. However, the long-term outcome of subintimal angioplasty has not been determined, and a limitation of subintimal angioplasty is the uncertainty in making the re-entry point. We report two cases, where occlusive in-stent restenosis occurred in a stent implanted in the subintimal space of the RCA that had CTO. These two cases were successfully treated with bypass restenting across the struts of an occluded subintimal stent using a retrograde approach. A retrograde wire crossed the occluded segment through the lumen along the outside of the stent and reentered the inside of the stent across the stent struts. The reverse CART technique followed by multiple restenting across the stent struts restored antegrade flow. Follow-up angiography demonstrated the patency of the RCA.

Rescue percutaneous coronary recanalization of right coronary artery by retrograde approach

We describe the case of a 62-year-old female patient in whom there was an occlusion of collaterals and acute inferior wall ischemia during the opening procedure of right coronary artery (RCA) chronic total occlusion. Rescue percutaneous coronary intervention (PCI) of RCA by the retrograde approach was performed preventing heart muscle damage. In this article we discuss the issue of PCI by the retrograde technique.