Application of the Hybrid Approach to Chronic Total Coronary Occlusion Percutaneous Coronary Intervention

Abstract

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) continues to evolve constantly with developing equipment and techniques. The hybrid approach to CTO PCI advocates dual coronary injection, careful and structured review of the angiogram, and flexibility. Use of all crossing strategies [antegrade wire escalation, antegrade dissection re-entry and retrograde approach] is encouraged, with initial and subsequent choices influenced by the CTO anatomic characteristics and the outcomes of the originally selected approach. Application of the hybrid approach to CTO PCI has been associated with good outcomes in US and European registries, although CTO PCI outcomes in non-selected populations have been less optimal with approximately 60% success rate. We analyzed the clinical, angiographic, and procedural characteristics of 3,122 CTO PCIs performed in 3,055 patients to determine the techniques and outcomes of hybrid CTO PCI in a diverse group of patients and operators in two continents (at eighteen US, one European, and one Russian centers ) enrolled in the PROGRESS-CTO (PROspective Global REgiStry for the Study of Chronic Total Occlusion Intervention, NCT02061436) registry between January 2012 and November 2017. Technical success rate was 87% and the risk for in-hospital major complications was 3%, providing important benchmarks to use when discussing with patients and providers the risk/benefit ratio of CTO PCI. The final successful crossing strategy was antegrade wire escalation in 52%, retrograde in 27%, and antegrade dissection reentry in 21%; more than 1 crossing strategies were required in 41% of the cases. CTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the US and Europe. Bridging the gap between what is currently achieved and what can be achieved in chronic total occlusion intervention should be a major focus of upcoming research and education efforts.

Outcomes with retrograde versus antegrade chronic total occlusion revascularization

“…Several observational studies 26–31 and two RCTs 32,33 have reported that successful CTO PCI is associated with improvement in the quality of life, reduced need for CABG, improved left ventricular (LV) function, and LV reverse remodeling compared with failed revascularization. The retrograde approach is currently an essential tool for achieving high success rates, especially in complex lesions where the antegrade approach is not technically feasible or fails 34 . According to the hybrid algorithm, proximal cap ambiguity, poor‐quality distal vessel and the presence of interventional collaterals favor the use of the retrograde approach 35 .…”

Equipment utilization in chronic total occlusion percutaneous coronary interventions: Insights from the PROGRESS‐CTO registry

“…As previously described, the antegrade approach remains the most commonly used CTO crossing technique 3,14‐17 . Higher lesion complexity (higher J‐CTO score, in‐stent restenosis, distal cap at bifurcation, proximal cap ambiguity, moderate/severe calcification, moderate/severe tortuosity and blunt/no stamp) were associated with utilization of larger number of guidewires.…”

“…Percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs) has evolved significantly during recent years, in large part due to developments in crossing techniques and advances in microcatheter and guidewire technology 1‐4 . Antegrade wiring remains the most common crossing strategy, 5 although more complex cases are more likely to require antegrade dissection and re‐entry and the retrograde approach 6,7 .…”

Clinical study of patients with coronary artery disease combined multivessel disease

“…Left main lesion (unprotected left main diseases) refers to the degree of left main coronary artery angiography stenosis greater than or equal to 50% of the lesions, and at the same time does not exist unblocked blood vessel bridge good collateral circulation or their right to left. CTO is a dynamic process from quantitative change to qualitative change after coronary artery atherosclerosis, the lesions usually begin with the rupture of the "vulnerable plaque" in the coronary arteries, forming clots at both ends of the plaque and which endly leading to complete occlusion of the coronary arteries [4][5][6][7][8] .…”