Chapter

Chronic Total Occlusions: A Guide to Recanalization

Copyright

Contents

List of Contributors

Foreword

Preface

Part I Pathology, Indications, and Review of Clinical Trials

Chapter 1 The pathobiology of CTO

Introduction

Current paradigm of CTO evolution

Development of CTOs

Neovascularization and angiogenesis

Calcification

Current research in CTO pathobiology

CTO imaging techniques

Summary

References

Chapter 2 Collateral circulation in CTO

Introduction

Coronary collateral arteries in healthy individuals in patients affected by CAD and after acute myocardial infarction

Stimuli of coronary collateral growth

Coronary collateral arteries classification

The prognostic value of collateral circulation

Changes in collateral circulation after CTO recanalization

References

Chapter 3 CTO: review of trials

Factors associated with successful CTO-PCI

Clinical benefits of CTO-PCI

Drug-eluting stents in CTO-PCI

Long-term follow-up

Conclusions

References

Chapter 4 CTO-percutaneous coronary intervention: what is the evidence?

Introduction

Outcome benefits associated with CTO-PCI

Predictors of CTO-PCI success

CTO-PCI techniques – planning the PCI strategy

Predictors of reocclusion and restenosis

Conclusions

References

Chapter 5 Case selection and long-term benefits

Prevalence of chronic total occlusion

Prognosis with CTO

CTO-PCI trends

Case selection and long-term benefits

Conclusion

References

Part II Imaging

Chapter 6 CT angiography: application in chronic total occlusions

Introduction

Overview of utility of CT scan to the coronary artery disease

Pathology

How is pathology reflected by CTA imaging?

What do we expect to see based on the CT density and spatial resolution?

Clinical results to date and impact on the interventional procedure

Future perspectives

Conclusions

References

Chapter 7 Co-registration CTO and CT angiography

Introduction

How image co-registration is performed

Initial experience using co-registration for CTO PCI

Conclusion

References

Chapter 8 Optical coherence tomography to guide the treatment of chronic total occlusions

Introduction

Principles of intra-coronary optical coherence tomography

Use of OCT for CTO assessment before stenting

Use of OCT to optimize stent deployment

OCT to assess the long-term success of PCI for CTO

Conclusion

References

Chapter 9 IVUS-guided CTO-PCI

Introduction

The role of IVUS-guided PCI for CTO lesions

Devices for IVUS-guided CTO-PCI with the antegrade approach

How to perform IVUS guided CTO-PCI with the antegrade approach

Impact of IVUS guidance on overall success rate

Conclusion

References

Chapter 10 IVUS evaluation of CTO

Introduction

IVUS morphological findings

IVUS findings during intervention

IVUS findings for follow-up after CTO procedures

References

Chapter 11 Magnetic navigation wire

Introduction

The current and future magnetic navigation wires

Navigational modes to orientate the magnetic tip

The theory of radiofrequency (RF) ablation in CTO

Magnetic navigation and MSCT co-integration in CTOs

Limitations

Conclusion

References

Part III Wires Technology

Chapter 12 Deflecting wire systems

References

Chapter 13 Asahi wires

Introduction

Important parameters for PCI guidewires

Line-up of Asahi guidewires for CTO lesions

Classification of Asahi guidewires for CTO lesions according to technique

Conclusion

Chapter 14 IVUS-guided recanalization of CTO

IVUS-guided wiring at CTO entrance

IVUS-guided penetration from subintimal space

References

Chapter 15 Frontrunner CTO technology

References

Chapter 16 Channel dilator: Corsair

Introduction

Structure of Corsair microcatheter

Retrograde approach and the role of the Corsair channel dilator

Case example of the successful recanalization of a complex CTO lesion with a Corsair microcatheter

Corsair Registry

Complications

Antegrade use of Corsair

Conclusions

References

Part IV Wires Technique

Chapter 17 Tornus catheter

Introduction

Device description

Penetration and removing

Breakage of the shaft

Another use of Tornus

Possible complication

Transradial approach

Case presentation

Acknowledgment

References

Chapter 18 Antegrade approach: step by step

Step 1: preparation

Step 2: access and guiding catheters

Step 3: wire selection

Step 4: wire shaping

Step 5: single wire manipulation

Step 6: the parallel wire technique

Step 7: penetrating the distal fibrous cap

Step 8: seesaw technique and beyond

Step 9: when to stop antegrade

References

Chapter 19 Use of two wires in the treatment of CTO

Use of a second wire for guiding catheter stability (anchoring wire technique)

Use of a second wire for side-branch protection

Second wire for correction of proximal tortuousities

Need for different types of wire for crossing the lesion

Two wires or more for parallel wire technique

Branch techniques

IVUS guidance

Wires and retrograde approach

Buddy wire technique

Anchoring balloon technique

Anchoring stent technique

Conclusion

References

Chapter 20 Parallel-wire techniques

Introduction

Parallel-wire technique

Technique description

Use of the parallel-wire technique

Conclusion

References

Chapter 21 Guidewire handling techniques for CTO lesions

Introduction

Unique physical properties of CTO guidewires

How to shape the tip of the guidewire

Use of an over-the-wire system

How to handle the guidewires

Selection of guidewires and handling techniques

Adjunctive techniques

Conclusion

References

Chapter 22 Subintimal angioplasty in coronary CTO

Introduction

Subintimal angioplasty: the concept

When to use subintimal angioplasty technique

Subintimal angioplasty related techniques

STAR technique

CART

Reverse CART

LAST technique

Knuckle-wire technique

IVUS-guided CTO

Dedicated re-entry devices system

Conclusion

Disclosure

References

Chapter 23 Antegrade device assisted re-entry techniques

Conclusion

References

Chapter 24 The microchannel technique

Background

The theory

The technique

Outcomes

Intra-plaque therapy

Evolution of the technique

Summary

References

Chapter 25 The STAR technique

The origins of the technique

The evolution of the STAR technique: the “guided-STAR” technique

Analogies between the STAR technique and the CART and reverse CART technique

Clinical outcome and risk of stent thrombosis after STAR technique

New devices to facilitate the re-entry techniques: Stingray re-entry system and the newest plastic-jacket hydrophilic guidewires

Clinical and procedural indications for the STAR technique and final considerations

References

Chapter 26 Attempting CTO after first failed attempt

Reasons for procedural failure

Rationale for attempting CTO after first failed attempt

Decision on the strategy after first failed attempt

Retrograde techniques following first failed CTO attempt

Inability to cross with the device following successful crossing of the guidewire

Clinical experience

Conclusions

References

Chapter 27 Transradial approach for CTO lesions and tapered-tip guidewires

Introduction

Rationale for the use of tapered-tip guidewire

Special considerations for TRI in CTO lesions

Novel techniques that are particularly useful during TRI

Conclusion

References

Chapter 28 Bilateral approach

Retrograde access

Chronic total occlusion crossing techniques in the retrograde approach

Conclusion

References

Chapter 29 Tips and tricks of the CART technique

Considerations in the CART technique

Tips and tricks

References

Part V Devices Technology

Chapter 30 Recanalizing total occlusion in the periphery: utilization of radio frequency and other technology

Introduction

Pathology of total occlusion

Patient selection

Crossing total occlusions

Subintimal angioplasty

Re-entry devices

Angioplasty and stenting

Complications

Chronic total occlusion devices

Medical management

Future technologies

Conclusions

References

Chapter 31 High-frequency mechanical revascularization

The Crosser system

Clinical study results

Clinical impact and future perspective

References

Chapter 32 Debulking of CTO

Indications of plaque debulking

Outcome of CTO-PCI

Role of plaque debulking in CTO-PCI

Conclusion

References

Chapter 33 Vibrational angioplasty

Introduction

Technology description

Vibrational angioplasty procedure

Advantages and potential disadvantages

Experimental experience

Clinical experience

Is vibrational angioplasty still a useful tool?

References

Chapter 34 Treatment of chronic total coronary occlusions with drug-eluting stents: overview of angiographic and clinical outcomes

Introduction

Clinical rationale for DES in percutaneous revascularization of coronary occlusions

Contemporary DES trials in CTO revascularization

Conclusion

References

Chapter 35 Laser for CTO recanalization

Introduction

Clinical applications of laser

Laser technology

Coronary total occlusions

SFA total occlusions

Total occlusions in critical limb ischemia

Summary

References

Chapter 36 The ENABLER-P: a novel CTO crossing cystem

Introduction

The ENABLER-P Balloon Catheter System

Clinical experience

Tips and tricks using the ENABLER-P Balloon Catheter System

Current perspective and future direction

References

Chapter 37 Collagenase plaque digestion for facilitating guidewire crossing

Introduction

Collagens: the major structural components of the extracellular matrix

Collagenase formulations

Rabbit models of femoral artery CTO

Collagenase local delivery rabbit model

Clinical experience with collagenase

The Collagenase Total Occlusion-1 (CTO-1) clinical trial

Summary

Future directions

References

Chapter 38 The BridgePoint re-entry system

Introduction

Device description and technique for use

Clinical experience

Conclusion

References

Part VI Complications

Chapter 39 Complications during the retrograde approach for CTO

Introduction

Classification of complications

Summary

References

Chapter 40 CTO: how to minimize contrast nephropathy

Introduction

Chronic total occlusions

Definition

Pathophysiology

Risk factors

Prophylactic measures

Summary

References

Part VII Interesting Cases

Chapter 41 Interesting cases I–VI

Case I (Figures  41.1, 41.2, 41.3)

Case II (Figure  41.4)

Case III [1] (Figure  41.5)

Case IV [2] (Insert Figure  41.6)

Case V (Figure  41.7)

Case VI (Figure  41.8)

References

Index