Antithrombotic Therapy in Chronic Total Occlusion Interventions

Abstract

Chronic total occlusion (CTO) recanalization is among the most complex subsets of coronary interventions. Hence, optimum peri- and post-procedural anticoagulation and antiplatelet therapy is key for the achievement of successful revascularization and reduction of major adverse cardiovascular outcomes in patients undergoing CTO percutaneous coronary intervention (PCI). Unfractionated heparin is still considered the gold standard anticoagulant because its action can be reversed by protamine administration, with bivalirudin being reserved mainly for patients with heparin-induced thrombocytopenia. However, small studies comparing unfractionated heparin with bivalirudin in CTO interventions have shown similar outcomes. Glycoprotein IIb/IIIa inhibitors should, in general, be avoided. Aspirin in combination with clopidogrel for 6–12 months is the standard post CTO PCI dual antiplatelet regimen. For the most complex cases, clopidogrel can be substituted by a more potent P2Y12 inhibitor, namely ticagrelor or prasugrel.

Recanalisation of coronary chronic total occlusions

“…There are no specific randomised trials that suggest whether the intensity and duration of antiplatelet treatment should be modified for CTO procedures and results from existing observational studies are conflicting 128,129 . An individualised approach is often applied based on a combination of existing scores of bleeding and recurrent ischaemia and specific procedural CTO characteristics (length of stented segment, long subintimal tracking, less than TIMI [Thrombolysis In Myocardial Infarction] 3 post-procedural flow) 128,[130][131][132][133] .…”

Periprocedural Antithrombotic Treatment in Complex Percutaneous Coronary Intervention

“…These recommendations are derived mainly from expert opinion rather than data from trials. 32 In the ATOLL trial (Acute Myocardial Infarction Treated with Primary Angioplasty and Intravenous Enoxaparin or Unfractionated Heparin to Lower Ischemic and Bleeding Events at Short-and Long-term Follow-up), which enrolled a total of 910 STEMI patients, intravenous enoxaparin compared with UFH, achieved a nonsignificant reduction in clinical ischemic outcomes without an increase in bleedings. The primary endpoint, consisting of the 30-day incidence of death, MI, procedure failure, and major bleeding, occurred in 28% of patients in the enoxaparin group compared with 34% of patients in the UFH arm [relative risk (RR) 0.83, 95% CI 0.68-1.01, P = 0.06].…”