Percutaneous Coronary Intervention for Chronic Total Occlusion: The Hybrid Approach

Foreword
Preface of the First edition
Preface of the Second edition
Contents
About the Editor
1: What Is What: Important Definitions in Chronic Total Occlusion Percutaneous Coronary Intervention
Introduction
Anatomical and Procedural Definitions
Efficacy and Safety Endpoints
Conclusion
References
2: The Histopathophysiology of Chronic Total Occlusion and Its Impact on Mode of Treatment
Introduction
Mechanisms of Lesion Progression and Histologic Studies of CTO
Characteristics of the Arterial Wall
The Lesion Characteristics of CTO With or Without Prior CABG
Clinical Translation from a Pathological Point of View
Conclusions
References
3: Who Are Best Candidates for Chronic Total Occlusion Revascularization
Introduction
Prior Evidence
EXPLORE Trial
REVASC Trial
EUROCTO Trial
DECISION-CTO Trial
Conclusions from Trials
Which Patients Are Best Candidates?
Final Remarks
Conclusions
References
4: Why, When and How to Assess Ischemia and Viability in Patients with Chronic Total Occlusions
Introduction
Ischemia, Hibernation, and Viability
Why to Assess Ischemia and Viability?
Ischemia
Ischemia and Collaterals, and After Opening the CTO
Ischemia and Prognosis
Ischemia and Symptoms
Viability
When to Assess Ischemia and Viability?
Guideline Recommendations
STEMI Patients with a CTO
Stable Patients with a CTO
Case Examples
How to Assess Ischemia and Viability?
Ischemia
Nuclear Myocardial Perfusion Imaging
Stress Echocardiography
Stress Cardiac Magnetic Resonance Imaging
Viability
Stress Echocardiography
Cardiac Magnetic Resonance Imaging
Nuclear Imaging
Conclusion
References
5: How to Set Up a Chronic Total Occlusion Angioplasty Program
Introduction
Developing CTO Skills
Operator Selection
Operator Training
CTO Program Built Around Two Operators
Infrastructure
Cardiac Catheterization Laboratory Volume
Cardiac Catheterization Laboratory
Cardiac Surgery Program/Extracorporeal Membrane Oxygenation (ECMO)
Nonmedical Staff
Administrative Support
Quality Control
Pre-procedure: CTO Clinic
Pre-PCI Explanation of the Plan
Post Procedure: CTO Rounds
Getting Started, the Practicalities
References
6: Equipment Requirement for Chronic Total Occlusion Percutaneous Coronary Intervention
Sheaths
Guide Catheters
Microcatheters
Finecross
Corsair Series
Turnpike Series
Mamba Series
Guidewires
Dissection/Reentry Equipment
Guide Catheter Extensions
Snares
Equipment for “Uncrossable–Undilatable” Lesions
Intravascular Ultrasound (IVUS)
Complication Management Equipment
References
7: The Hybrid Approach and Its Variations for Chronic Total Occlusion Percutaneous Coronary Intervention
Introduction and Historical Perspective
Simplifying the Complex
The Algorithms…. Combined
Who Should Do the Procedure?
Pre-procedure Coronary CT Angiography
Choosing the Initial Strategy
Antegrade Wiring
Secondary and Bailout Strategies with Primary AW Approach
Antegrade Dissection and Reentry (ADR)
The Retrograde Approach
In-Stent Chronic Total Occlusion
Switching Strategies
Ending the Procedure
Conclusions
References
8: When, Why, and How to Perform Good Angiographic Analysis Before CTO PCI
Introduction
When and Why
How
CTO Angiography
CTO Angiographic Analysis
Target Vessel
CTO Characteristics
Donor Vessels
Collateral Circulation
Collateral Pathways
Interventional Collaterals
Conclusion
References
9: Specific Basic Techniques to Master in CTO PCI
Approaching the CTO Segment
Wire Manipulation Techniques in CTO
Trapping Balloon Technique
References
10: When, Why and How to Perform an Antegrade Approach Using a Wiring Technique
Introduction
Anatomical Subsets That Favor Antegrade Wiring
Lesion Length
Proximal Cap Anatomy
In-CTO Tortuosity (>45°)
Presence of Intra-CTO Calcium
Previous Procedural Failure
Other Factors
Degree of Disease in the “Distal Landing Zone”
Presence of “Interventional Collaterals”
Basic Principles of CTO PCI
Planning
Visibility
Backup Support
Use of “Over-the-Wire” Equipment
Wire Selection
Tapered Polymer-Coated Wires
Medium Weight Wires
High Gram Weight Wires
The Proximal Cap and How to Assess It
Wire Selection: Principles and Rationale
Polymer-Coated Wires
Penetration Force
Tactile Feel
Torque Transmission
Wire Selection
Wire Shaping
Confirming Progress and Ensuring Safety
Confirming True Lumen Entry
Angiographically
Wire Feel
Intravascular Ultrasound (IVUS)
Advancing Equipment
Anchor Balloon
Guide Extension
Higher Support Microcatheter
Laser Atherectomy
Rotational Atherectomy
Indications and Use of Adjunctive Imaging Strategies
CTA
IVUS
When to Switch Strategy
References
11: When, Why, and How to Perform Wire-Based Antegrade Dissection and Reentry Technique
References
12: When and How to Perform Contemporary Device-Based Antegrade Dissection and Re-entry Technique
Introduction
Evolution of Strategies for ADR
Primary ADR: A Step-by-Step Approach
Troubleshooting ADR Procedures and Bailout Manoeuvres
Outcomes with ADR in Contemporary Practice
Conclusions
References
13: How to Deal with Difficult Antegrade Issues
Difficult Antegrade Issues That Apply to Both AW and ADR
Ambiguous Proximal Cap
Impenetrable Cap
Uncrossable Lesion
Difficult Antegrade Issues That Are Unique to Antegrade Dissection Reentry
Crossboss Challenges
Reentry Challenges
References
14: Intra-occlusion Microinjection of Contrast: When, Why, and How
References
15: When, Why, and How to Perform the Antegrade Fenestration and Reentry Technique
Introduction
Pathophysiological Bases and Development of Antegrade Fenestration and Reentry (AFR)
Procedural Description of Antegrade Fenestration and Reentry (AFR)
Real-Life Experience with Antegrade Fenestration and Reentry (AFR)
Role of Antegrade Fenestration and Reentry (AFR) in the Hybrid Algorithm
Further Developments in Antegrade Fenestration and Reentry (AFR)
Conclusions
References
16: When, Why, and How to Perform the Retrograde Approach Through Septal Collateral Channels
When to Select the Retrograde Approach: How to Analyze the Coronary Angiography
How to Set Up the Procedure
Pathways to the Distal Cap (Table 16.1)
Collateral Channels
Step-by-Step Approach
Selecting the Microcatheter, Crossing the Collateral Channel with a Wire, and the Microcatheter
Selecting the Microcatheter
Crossing a Septal CC with the Wire
Surfing from PDA to LAD: A More Difficult Task
Advancing the Microcatheter to the Distal Cap Through the Septal CC
Special Situations and Considerations
Using an Internal Mammary Artery as a Donor Artery to Septal CCs
LAD or LCX CTOs in a Dominant Left System
References
17: When, Why, and How to Perform the Retrograde Approach Through Epicardial and Non-septal Collateral Channels
When to Perform Retrograde CTO PCI Via Non-septal Connections? Anatomic Evaluation
Algorithms for Performing Retrograde Approach
Collateral Channel Scores
Why Performing Retrograde CTO PCI Via Non-septal CCs? Clinical Evaluation
Indication and Timing of Using Non-septal Collateral CCs
Risk-Benefit Assessment of Selecting Non-septal CCs
How to Perform Retrograde CTO PCI Via Non-septal Connections: Practical Considerations
Arterial Access
Non-septal Collateral Channel Crossing
Crossing the CTO
Externalization
Complications Related to Retrograde CTO PCI Via Non-septal Connections
Perforation of the CC When the CTO Is Crossed
Perforation of the CC When the CTO Remains Uncrossed
References
18: When, Why, and How to Perform the Retrograde Approach Through Patent or Occluded SVGs
Introduction
CTO PCI in Post-CABG Patients
Retrograde Approach Through an SVG
Retrograde Via Diseased But Patent SVGs
Retrograde Via Occluded SVGs
Guide Extensions in SVGs
Specific Situations
Stumpless SVG Use
Retrograde Access Via Acutely or Recently Thrombosed SVG in ACS Patients
How to Deal with Acute Angle of Distal Anastomosis
Distal Anastomosis Ambiguity
Stenting Coronary Across Distal SVG Anastomosis After CTO PCI
Dealing with Anastomotic Stents in SVGs
Protecting the Graft
What To Do with the SVG Once the Native Artery CTO is Open?
Potential Complications When Using SVGs as Retrograde Conduits
Distal Embolization
SVG Perforation
Aortic Dissection
Mediastinal Bleeding/Haematoma
References
19: How to Cross the Occlusion Using a Retrograde Approach, How to Externalize, and How to Snare Long Wires
Introduction
Retrograde Wiring
Wire Choice
Confirming Wire Position
Note on Safety in RW
Retrograde Dissection and Re-entry
Creating an Antegrade Dissection
Use of Guide Catheter Extension
Creating a Retrograde Dissection
Joining the Spaces
Externalization
Use of Snare for Externalization
Principles of Snaring
How to Snare
Positioning of Retrograde Microcatheter After Externalization
Removal of Retrograde Equipment
Troubleshooting
Unable to Create Common Space
Both Wires in the Same Compartment
Wires in Different Compartments
Unable to Advance Retrograde Microcatheter Through the CTO
Retrograde Guidewire Tracking a Saphenous Vein Graft Remnant
References
20: How to Manage Ostial Right Coronary Artery Chronic Total Occlusions and to Perform Externalization Techniques
Introduction
Access and Guide Catheter Selection
Algorithm Part 1: Antegrade-Crossing Attempt Is Possible
Algorithm Part 2: Antegrade Crossing Not Possible
Algorithm Part 3: Retrograde Guidewire Externalization
Conclusions
References
21: CTO Stenting: Impact of Intraplaque and Extraplaque Strategies
Introduction
Lesion Preparation
The Role of Intravascular Imaging
Intraplaque Versus Extraplaque Stenting
Duration of Dual Antiplatelet Therapy After CTO PCI
Conclusions
References
22: When, Why, and How to Recanalize In-Stent Chronic Total Occlusions
Introduction
Prevalence
What Is Unique to In-Stent Occlusions?
Pathophysiology
In-Stent Occlusive Re-stenosis
In-Stent CTO from Previous Thrombosis
Angiographic Appearance of In-Stent CTOs
When and Why to Recanalize In-Stent Occlusions?
Treatment Algorithm that Applies to this Entity
Hybrid Approach for IS CTO
Antegrade Wiring
CrossBoss for IS CTO
Retrograde Approach
Long-Term Outcomes
Problem-Solving Strategies
Conclusions
References
23: When, Why, and How to Fix Common Problems Encountered in Chronic Total Occlusion Percutaneous Coronary Intervention: The Expanded Hybrid Approach
Wire Impenetrable Cap Despite Standard Wire Escalation
Wire Across Cap/Lesion but Gear Will Not Follow Algorithm
Working Over the Initial Wire
Solutions that Require Sacrificing the Initial Wire Position
CTO Cap Ambiguity Algorithms
Proximal Cap Ambiguity
Distal Cap Ambiguity
Difficult Anterograde Dissection Reentry Algorithm
Wire Across Retrograde Collateral but Microcatheter Will Not Follow Algorithms
Septal Algorithm
Bypass Graft Algorithm
Epicardial Algorithm
Difficult Retrograde Dissection Reentry (R-CART) Algorithm
Inability to Externalize Wire During R-CART Algorithms
Retrograde Wire Is in Anterograde Guide but the MC Will Not Follow
When the Retrograde MC Has Reached the Anterograde Guide, but the Externalization Wire Will Not Progress
Wire/Gear Track into a Side Branch at a Cap or Within a Lesion Algorithm
Difficulty Crossing Due to Graft Insertion (Suture Line) Algorithm
In-Stent CTO Algorithm
Conclusion
References
24: Why, When, and How to Perform Plaque Modification and Subintimal Tracking and Re-entry with Deferred Stenting for Failed Chronic Total Occlusion Percutaneous Coronary Intervention Cases
Introduction
Why?
When?
How?
Conclusion
References
25: Why IVUS When Approaching a CTO?
Introduction
Types of IVUS More Commonly Used
Indications
Antegrade Approach
Entry Point Evaluation and Wire Penetration in Ambiguous Proximal Cap
IVUS for ADR
Retrograde Approach
Difficult Re-entry in Retrograde Approach: True Ostial CTOs
IVUS for Retrograde Dissection and Re-entry: Confirming Wire Position, Guiding Balloon Sizing, Assisting with Connection of Wires
IVUS for Coronary Sizing, Stent Implantation, and Optimization During CTO PCI
Limitations
Conclusions
References
26: How to Manage Calcified Chronic Total Occlusion Lesions
Introduction
Preprocedural Assessment of Calcified CTO
Post Bypass Native Vessel CTOs
Management of Calcified CTOs
Calcium and CTO Crossing
Procedural Setup
Proximal Cap Calcium
Occlusive Segment Calcium
Distal Cap Calcium
Reentry Zone Calcium
Calcium Modification
Conclusion
References
27: How to Improve Catheter Support During Chronic Total Occlusion Percutaneous Coronary Intervention?
Introduction
Access Choice
Recommendations
Sheaths
Recommendations
Guide Catheters
Size, Length, and Stiffness
Shape
Recommendations
Guide Catheter Extensions
Recommendations
Anchoring Techniques
Recommendations
Microcatheters
Recommendations
Retrograde Approach
Recommendations
Conclusions
References
28: When, Why, and How to Perform a Transradial Approach for Chronic Total Occlusion Percutaneous Coronary Intervention
Rationale for Radial Artery Access in CTO PCI
When to Choose the Radial Artery Access
Patient Positioning and Obtaining Access
Introducer Sheath Selection
Guide Catheter Selection and Enhancing Support from the Radial Artery
Advancing and Manipulating the Guide Catheter
Sheathless Guide Catheters
Commercially Available Sheathless Guide Catheters
The Hybrid Algorithm and Radial Artery Access
Conclusion
References
29: How to Manage Radiation and Contrast During Chronic Total Occlusion Percutaneous Coronary Intervention
Contrast-Induced Acute Kidney Injury in CTO Percutaneous Coronary Interventions
Definitions of Contrast-Induced Acute Kidney Injury
Incidence of Contrast-Induced Acute Kidney in CTO Procedures
Risk Factors for Contrast-Induced Acute Kidney in CTO Procedures
Prognostic Impact of Contrast-Induced Acute Kidney
Prevention of Contrast-Induced Acute Kidney in CTO Procedures
Pre-procedural Strategies
Intra-procedural Strategies
General Measures
Procedural Techniques
Forced Diuresis (RenalGuard System)
Coronary Sinus Contrast Media Extraction (CINCOR System)
Follow Up
Radiation Exposure Complications in CTO Interventions
Radiation Doses in CTO Procedures
Deterministic Effects
Stochastic Effects
Radiation Exposure Effects to Operators
Methods for Reducing Radiation During CTO Interventions
Pre-procedural Strategies
Intra-procedural Strategies
General Measures
CTO-Specific Techniques
Post-procedural Strategies and Follow-Up
Conclusions
References
30: Why, When, and How to Use Left-Ventricular Assist Devices During Chronic Total Occlusion Percutaneous Coronary Intervention
References
31: Specific Considerations When Performing CTO PCI in Post-CABG Patients
Introduction
Post-CABG Patients and CTO Lesions
The Distal CTO Cap Is Submitted to SVG Flow (Systemic Pressure)
Multiple Sources of Collateral Flow, Often Epicardial
Retrograde via Occluded or Diseased Bypass Grafts
Retrograde via Radial Graft
Retrograde Through Internal Mammary Artery (IMA) Grafts
Opening One CTO in Order to Open Another CTO
Remnants of SVG Grafts Anastomosed to Distal Vessels
Biplane Angiography
Access in Post-CABG CTO Cases
Radial vs. Femoral Approach
Bilateral Radial Approach in Post-CABG
Sheathless Transradial
Femoral Approach
Third Arterial Access
Dual Retrograde vs. Triple Access
Triple Injections Setup
Retrograde Guide Length
Tenting of the Vessel by Old Grafts
Consideration of Mechanical Circulatory Support with Impella CP
STEMI in Post-CABG
Complications in Post-CABG Are Different
Loculated Pericardial Effusion
True Tamponade in a Post-CABG Patient
Distal Wire Perforation
Post-CABG CTO Cases as a Learning Opportunity
References
32: An Overview of Chronic Total Occlusion Percutaneous Coronary Intervention Complications
Antegrade Complications
Retrograde Complications
The Patient with Prior Coronary Artery Bypass Graft Surgery
How to Prevent Complications
How to React Once a Complication Has Occurred
References
33: Management and Prevention of Perforations During Chronic Total Occlusion Percutaneous Coronary Intervention
Outcomes and Predictors of Coronary Perforations During CTO PCI
Classifications and Risk Stratification of Coronary Perforations
Management of Perforation
Prevention
Conclusions
References
34: How to Prevent and Manage Ischemic Complications During CTO PCI
General Overview
Ischemic Complications from Target CTO Vessel Injury
Ischemic Complications from Donor Vessel Injury
Ischemic Complications from Collateral Channel Injury
References
35: Managing Entrapped Gear During Chronic Total Occlusion Interventions
Introduction
Risk Factors
Management of Equipment Entrapment and Loss
Wires
Bailout Technique for Trapped Wires
Microcatheters, Balloons, and Stents
Bailout Techniques for Trapped Stents, Microcatheters, and Balloons
Rotablator Burr
Bailout Techniques for Trapped Rotablator Burr
Retrograde Scenarios
Bailout Techniques for Retrograde Entrapment
Managing Complications
Management of Major Complications
Conclusions
References
36: When, Why, and How to Perform Robotic-Assisted CTO PCI
Introduction
Why Perform Robotic-Assisted PCI?
Data for Robotic-Assisted PCI
How to Perform Robotic-Assisted PCI, Step-by-Step
Future Directions
Conclusions
References
37: How to Proctor New Operators to Learn CTO PCI
Introduction
Training New Operators in CTO PCI as Part of a Dedicated Fellowship
Training Established Operators to Perform CTO PCI
Questions to Ask yourself
Question to Ask the Sponsor
Prior to the Proctoring Day
On the Day of Proctoring
End of the Day
Conclusion
38: How to Start and Build Your CTO Practice and Maintain Referrals in a Competitive Environment
Introduction
The New CTO Operator Should Know the Data
The New CTO Operator Should Know Himself or Herself
The New CTO Operator Should Educate Him or Herself
The New CTO Operator Should Get a Mentor
The New CTO Operator Should Start a Dedicated Program
The New CTO Operator Should Understand that CTOs Should Not Be Attempted Ad Hoc
The New CTO Operator Should Learn to ‘Walk Before Running’ When Starting Alone
An Ounce of Prevention…
The New CTO Operator Should Get Ready to Fail
The New CTO Operator Should Track Outcomes
The New CTO Operator Should Grow His or Her Program
The New CTO Operator Should Keep Learning
Conclusion
Index